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Full text of "A Treatise on pathological anatomy (volume 1)"







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THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




PRESENTED BY 



J)r. ^.Tou Thrift s 




V 






, ' 



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^ A TREATISE /f^^ 



PATHOLOGICAL 
ANATOMY: 

BY G. ANDRAL, 

>* 

PROFESSOR TO THE FACULTY OF MEDICINE OF PARIS, MEMBER OF THE R07AL 

ACADEMY OF MEDICINE, OF THE COUNCIL OF HEALTH, 

ETC. ETC. 



TRANSLATED FROM THE FRENCH, 
BY 

RICHARD TOWNSEND, A.B., M.D., M.R.I.A. 

AND 

WILLIAM WEST, A.M., M.D., M.R.I.A. 



VOL. I. 

EMORY UNIVERSITY 

THE A. W. CALHOUN MEDICAL LIBRARY 
NEW YORK: 

SAMUEL WOOD & SONS, 261 PEARL-STREET. 

1832. 



PRINTED AT THE OFFICE 

OP THE 

MEDICO-CHIRURGICAL REVIEW, 

NO. 261 PEARL-STREET. 

rW &<j^ 14.. -..;.., 




AUTHOR'S PREFACE. 



At no other period has Pathological Anatomy been so gen- 
erally studied ; it has in some degree suggested the idea of 
the great works that have been undertaken for these last 
thirty years, and accordingly it has almost exclusively reaped 
the profit of them. It engages the general attention to such a 
degree, that our Periodicals are filled with facts relating to it, 
and every day brings forward new ones. We have reason to 
congratulate ourselves on the great assistance this will be to 
the science ; but, more than this is needed, and people are 
now beginning to feel the necessity of works which, by col- 
lecting the scattered facts, presenting them in their various 
lights, and comparing them with one another, shall recapitulate 
what has been done, and prepare for what still remains to do. 
It appears to me, however, that it is not at a period when 
every one, so far from looking back on past researches, or 
even pausing to consider those of the present day, is anxious- 
ly engaged in new ones, that such a work can well be pub- 
lished : it would soon become obsolete, and it could never 
give but an imperfect view of the state of the science. I do 
not, then, pretend to offer to the public a complete treatise on 
Pathological Anatomy, but only an account of the method I 
have followed in the study of that science, with a view to 
determine its connexion with the practice of medicine. 

In the first part of this work I have endeavoured to set 
forth, under the title of General Pathological Anatomy, all 
that the lesions of the body have in common, in their external 
form, their internal disposition, and their mode of production. 
In the second part, to which I have given the title of Special 
Pathological Anatomy, I have attempted to apply to the his- 
tory of the diseases of some apparatuses the method pursued 
in the first. I have chosen those of which the diseases, being 



iv author's preface. 

more especially within the province of the pathology of the 
interior, have been also more especially the objects of my 
study. 

I have endeavoured to ascend to the causes of the lesions 
described, and to discover their relations, and their modes of 
connexion and succession. I have discussed the importance 
of the part they play in the production of diseases, and have 
inquired how far an acquaintance with them can assist us in 
determining the seat and nature of these diseases. Lastly, 
I have examined what kind of influence pathological anatomy 
should have over therapeutics. I have considered it scarcely 
necessary to dwell upon the services it has rendered to med- 
icine ; for nobody now dreams of contesting the point : but, 
at the same time, I thought it of great importance to establish 
the limits beyond which it can afford us only insufficient or 
uncertain light. I had to shew that pathological anatomy is 
but one of the many points of view in which we may consider 
the science of disease. 

I have not described inflammation, because, that being a 
complex morbid state, I judged it preferable to describe sep- 
arately each of the lesions, the assemblage of which con- 
stitutes the inflammation of authors. I have not even em- 
ployed this antiquated expression, as it seemed to me fit only 
to make the language of the science vague and confused. 
Without troubling myself, therefore, about the various signi- 
fications successively attached to the words enteritis, pneu- 
monia, hepatitis, splenitis, nephritis, encephalitis, carditis, fyc. 
I have described the lesions of the organs such as they are 
found on examination, and I have at the same time inquired 
into the laws of their production. 

I am indebted to the kindness of M. Reynaud for some of 
the most important facts brought forward in this work ; and I 
cannot pass over in silence the generosity with which he has 
neglected his own fame by allowing me to make free use of 
the results of his labours. He must allow me to take this 
opportnnity of testifying my gratitude, and declaring what 
assistance I have had from his extensive information, and 
uncommon acuteness of intellect. 



TRANSLATOR'S PREFACE. 



As this translation is a joint production, it devolves upon me, 
as Editor, to explain the circumstances which have led to its 
being so, and to state what share my colleague and myself 
have had in it respectively. Dr. Townsend, who undertook 
it at the request of the author himself, had proceeded as far as 
the commencement of the article on tubercle, when, being 
obliged to go to the continent, he transferred it to me to com- 
plete and publish. At the same time, he left me at liberty to 
revise and correct his part of the translation as far as I might 
think it necessary ; which I have done accordingly. 

The first volume being in a manner complete in itself, I 
have considered it expedient to publish it at once, without 
waiting for the second, which shall appear as soon as my 
professional avocations will permit. 

w. w. 



CONTENTS 

OP THE FIRST VOLUME. 



PART FIRST. 

General Pathological Anatomy. 

Page. 

Preliminary Observations 3 

SECTION I. 
Lesions of Circulation 10 

CHAPTER I. 



Hyperaemia 

Art. I. Sthenic hyperaemia . 
Art.. II. Asthenic hyperaemia . 
Art. III. Mechanical hyperemia 
Art. IV. Hyperaemia formed after death 



CHAPTER 11. 



ib. 
11 
31 
39 

44 



Anaemia ........ 55 

Art. I. Local Anaemia . . . . . . ib. 

Art. II. General Anaemia 



60 



68 



SECTION II. 

Lesions of Nutrition 

CHAPTER I. 

Lesions of Nutrition depending on the irregular arrangement 
and distribution of the anatomical elements of 
which the solids of the body are in their natural 
state composed ..... en 



CONTENTS. 



CHAPTER II. 



Page, 



Lesions of Nutrition with respect to the number of molecules 

composing the different solids . . .123 

Art. I. Hypertrophy ib. 

Art. II. Atrophy . . . . ■ . . .137 
Art. III. Ulceration . . ... . .141 



CHAPTER III. 



Lesions of Nutrition which affect the consistence of the 
elementary particles constituting the different 
solids ........ 146 

Art. I. Induration ...... 149 

Art. II. Softening 160 



CHAPTER IV. 



Lesions of Nutrition, with respect to the nature of the mole- 
cules composing the different solids . . 173 
Art. I. Of the cellular transformation . . . 179 
Art. II. Of the serous transformation . . .180 
Art. II. Of the mucous transformation . .188 
Art. III. Of the cutaneons transformation . . 197 
Art. IV. Of the fibrous transformation . . 19S 
Art. V. Of the cartilaginous transformation . . 205 

I. Cartilaginous productions developed in the 

cellular tissue . . . . . ib. 

II. Cartilaginous productions developed in struc- 

ture of parenchymatous organs . 209 

HI. Cartilaginous productions existing loose in 

cavities ..... 212 

Art. V. — IV. Cartilaginous productions supplying the place 
of natural cartilages that had been 
destroyed . . . . .215 

Art. VI. Osseous transformation . . . .218 

I. Ossification of the cellular tissue . .219 

II. Ossification of the fibrous and cartilaginous 

tissues 222 



Lesions of Secretion 



CONTENTS. 

SECTION III. 

Page. 
• . • • 229 

CHAPTER I. 



Modifications in the quantity of the secretions . • -232 
Art. I. Hypercrinia with retention of the secretion . 233 
Art. II. Hypercrinia with discharge of the fluid . 250 

CHAPTER II. 

Modifications in the situation of the secretions . . . 260 

CHAPTER III. 

Modifications in the quality of the secretions . . . 268 
First Class. — Morbid secretions not susceptible of organiza- 
tion 292 

Second Class. — Morbid secretions susceptible of organization 354 
Third Class. — Morbid productions that are organized, and 

enjoy an undivided existence . . 372 

CHAPTER IV. 

Gaseous Secretions ••••... 385 

First Class. — Alterations of the gaseous secretions of the 

natural condition .... 386 
Second Class. — New gaseous secretions produced . . 387 

SECTION IV. 
Lesions of the blood 



SECTION V. 

Lesions of innervation 



388 



420 



PART L 



GENERAL MORBID ANATOMY 



PATHOLOGY, 



Vol. I. 



A TREATISE 

ON 

MORBID ANATOMY 

AND 

PATHOLOGY. 



PART FIRST. 

GENERAL PATHOLOGICAL ANATOMY. 



PRELIMINARY OBSERVATIONS. 

In every part of organized living matter, three grand fun- 
damental actions are uninterruptedly going forward ; namely, 
Capillary circulation, Nutrition, and Secretion. These phe- 
nomena, though presenting an almost infinite variety in their 
numerous degrees of simplicity or complication, are never- 
theless constant and uniform in their ultimate results. 

I. Capillary circulation. A fluid under the different de- 
nominations of Blood, Lymph, or Sap, deposits in the various 
tissues, and subsequently retakes from them, the materials of 
which all the solids and fluids are composed. In the intimate 
structure of every tissue, there exist a series of currents di- 
rected in their movements by forces independent of those 
which, in the human subject, serve to propel the blood through 
the arterial system. In this intimate structure (trame) of the 
tissues, the fluids and solids come into contact, and become as 
it were, blended together and amalgamated; and in it also the 
blood, or analogous fluid, is abstracted from the circulation, 
and becomes organized and endowed with vitality. Such is 
the capillary circulation : as widely diffused throughout the 



4 PRELIMINARY OBSERVATIONS. 

kingdom of nature as life itself, it is found in full force, after 
the heart, arteries, and veins, have disappeared, and in fetal 
life is accomplished long before the developement of these 
vessels. In some cases the nutritive fluid, when arrived at the 
parenchymatous substance of an organ, continues to circulate 
in distinct vessels, whilst in others it merely oscillates in sim- 
ple areolae of cellular tissue. 

II. Nutrition. This process consists in the several solids 
alternately receiving from, and returning to, the nutritive 
fluid, a succession of particles similar to those of which their 
structure is already composed. The blood which circulates 
through the system of capillary vessels has, when viewed with 
a microscope, been by many observers compared to a sort 
of whirlpool, from which various particles were constantly 
thrown off to the different solids, whilst others were detached 
from the solids, and flung back into the vortex of the cir- 
culation. 

III. Secretion. In the intimate structure of every tissue, 
as well as on its surface, in short, wherever a particle of the 
nutritive fluid comes into contact with a particle of living 
matter, there is a serous fluid produced without the aid or in- 
tervention of any peculiar secretory apparatus, such as is 
required for the production of all the other secretions, which 
are furnished each by a distinct glandular apparatus. 

These three phenomena just enumerated comprehend the 
fundamental principles of organization common to vegetables 
and the lower orders of animals ; but in man, and those animals 
occupying a place near him in the zoological scale, a fourth 
action is superadded, which exercises a powerful influence and 
control over the others. The nervous system is the seat and 
instrument of this action, which I shall denominate innerva- 
tion ! its influence over the acts of circulation, nutrition, and 
secretion, is the more absolute and indispensable the more 
elevated the rank the animal occupies in the scale of existence. 

Finally since all the materials of nutrition and secretion are 
derived directly from the blood, and since the blood contained 
in the capillary system differs in no respect from the general 
circulating mass, of which indeed it is only a fractional part, 



PRELIMINARY OBSERVATIONS. O 

it follows that the qualities of the general mass of blood must 
exercise a very material influence over all the phenomena of 
nutrition and secretion. Hence it is, that in the beings which 
have centres of nervous influence, and a systematic circulation, 
the life of each part is involved in the life of the whole, and 
there arises that relation of so many different actions to the 
whole and to each other, which constitutes the unity of the 
living system. 

The human body considered in the state of disease, presents 
only various modifications of those actions which have already 
been enumerated as essential to man in health. Thus, 

1. The supply of blood usually received by an organ in the 
healthy state of the system may be altered in its quantity ; 
from such alterations arise the lesions of the circulation. 

2. The component particles of the different solids are liable 
to various alterations in their arrangement, their number, 
their consistence, and their nature ; hence arise the lesions of 
nutrition. 

3. The different secretions which are separated from the 
blood in the parenchymatous structure of the organs, or on 
their surface, may be altered either in their quantity, or in 
their quality; and hence the lesions of secretion. 

Moreover, inasmuch as the state of the nervous system, 
and the composition of the blood, exert a powerful influence 
over the capillary circulation, nutrition, and secretion, in the 
healthy state, it is evident, that as they continue to exert the 
same influence in disease, many of the derangements of these 
actions must proceed from various alterations of innervation 
and sanguification. 

In conformity with these views, I propose dividing into 
five sections the various morbid alterations to which the 
human body is liable. 



SECTION I S ' ncrease °f quantity of blood. 

Lesions of Circulation. \ Diminmion of quantity of blood . 



PRELIMINARY OBSERVATIONS. 



SECTION II. 

Lesions of Nutrition. 



Alterations of the ar- ) 
rangement of the ele- > Malformations 

f Increase. \ 



mentary particles. 
— of their number 



of their consistence. 
l_ — of their nature. 



V. Diminution. 
C Softening. 
( Induration. 
< Transformation 



Hypertrophy. 

Atrophy. 

Ulceration. 



$ Effusion. 

I Flux. 



In elements. 



(Alteration in the C Increased quantity, 
quantity of the < 
secretions. ( Diminished quantity. 

f Developement in an"] . siihstanco 
SECTION III. I — in their situa- i unusual situation. ' 

Lesions of Secretion. } tion. j Translation to an un- 

l_ usual situation. 
— in their qual- C The natural secretion modified in its composition, 
ities. < 

( A new secretion. 

f Alterations in the Physical proper- ") Pvi ,„; Hv „ 
SECTION IV. J ties of the Blood. 

Lesions of the Blood 



— of its Chemical properties. f Conse( . mive 

— of its Physiological properties J ^ onse ™»ve. 



SECTION V. $ Primitive. 

Lesions of Innervation. ^ Consecutive . 



The derangements of the capillary circulation, secretion, 
and nutrition, may be divided into two distinct groups, accord- 
ing as they proceed from some local modification of the part 
affected, (as for instance erysipelas from exposure to the sun, 
or suppuration in the neighbourhood of a foreign body,) or as 
they are dependent on some peculiar alteration of the blood 
or of the nervous influence (e. g. scorbutic petechias and scrof- 
ulous abscesses). In this latter case the alteration that an 
organ suffers in its secretion, nutrition or circulation, is merely 
the translation of the external manifestation of some more gen- 
eral arrangement which produces a series of local affections. 
Thus, for example, the various lesions of nutrition which occur 
in srofulous individuals are assuredly not independent of each 
other ; on the contrary, they are all effects of the same cause, 
only rendered sensible to us by producing those modifications 
of secretion and nutrition which, taken together, constitute 
what we denominate " the scrofulous diathesis." 

A question here naturally suggests itself: Can we in all 
cases assign the cause of these morbid alterations ? Are they 
all produced (as has been confidently advanced) by the simple 
modification of the natural excitability, which, although some- 



PRELIMINARY OBSERVATIONS. 7 

times diminished, is much more frequently augmented, for their 
production ? As a period may be observed in almost every dis- 
order, during which some phenomena occur, that seem to indi- 
cate a local or general increase of the natural excitability, 
some pathologists have been led to consider this increased ex- 
citability, or rather the state of increased excitement itself, 
termed irritation, as the cause of the greater number of disor- 
ders, both functional and organic, to which the human body is 
liable. But it should be remembered, that the frequent occur- 
rence of a phenomenon by no means infers the necessity of 
its existence ; and that the coincidence of two circumstances 
does not prove the one to be the cause of the other. 

On the other hand, those pathologists who denied that irri- 
tation was the source from which the various lesions of nutri- 
trition and secretion were derived, would, in my opinion, have 
been more correct, hud they maintained, that irritation alone 
and unassisted, was incapable of producing them ; for to me it 
appears indisputable that there is not one of these lesions to 
the production of which irritation may not in some degree 
contribute. 

When a tissue has once been the seat of irritation, it is 
thereby rendered susceptible of every variety of alteration of 
secretion and nutrition ; of hypertrophy or atrophy, induration 
or softening ; cancer and tubercle, or cartilage and hydatid, 
<fcc. ; but in all these cases, irritation can only be considered as 
one of the elementary principles of the phenomenon ; as con- 
tributing more or less towards its production, but unable of 
itself to produce these lesions, or to account for the individual 
peculiarities of each morbid production. 

In some cases where the presence of irritation is not directly 
proved, we are authorized by the laws of legitimate induction, 
to infer its existence : many cases however occur, in which 
even this proof is inadmissible ; but in such cases we often 
have no better evidence of the existence of atony. All that 
we can observe is, a modification or perversion of the func- 
tions of nutrition and secretion : beyond that, all is mere con- 
jecture. 

The effect of irritation in such cases appears to me exclu- 



8 PRELIMINARY OBSERVATIONS. 

sively confined to the production of a derangement in the phe- 
nomena of secretion and nutrition ; but in theory we can 
conceive such a derangement taking place without the neces- 
sary pre-existence of any increase of the natural excitability. 
What necessary connexion is there, for instance, between an 
increase of excitement, and the deposition of tubercle or car- 
tilage in the cellular tissue, in place of the serous vapour that 
usually fills its areolae ? In theory irritation should be consid- 
ered as being frequently, but not necessarily, the precursor of 
the different organic alterations ; such is precisely the conclu- 
sion which an impartial observation of facts leads us to adopt. 
The part played by irritation in the state of disease, has 
been compared to that of excitation in the state of health : let 
us then endeavour to ascertain the nature and limits of the 
influence which this excitation exerts on the phenomena of 
health. The atmospheric air is justly considered as an exci- 
tant of the mucous membrane of the bronchia ; but the influ- 
ence of the air is by no means confined to this alone: it acts 
on the blood, produces in it certain peculiar modifications, both 
vital and chemical, and at the same time, many of its constitu- 
ent principles are directly absorbed and replaced by others. 
In this series of phenomena, excitement performs a very sec- 
ondary part, and is utterly insufficient to account for their pro- 
duction. In the same manner, food, when taken into the 
stomach, occasions by its presence an increase of vitality, and 
a determination of the fluids ; in short, it excites the stomach ; 
but in this case, as in the preceding, excitement is only one of 
the elements of the phenomenon, and no more explains the 
process of digestion in the stomach, than of the aeration of the 
blood in the lungs. The same remark is applicable to the dif- 
ferent secretions ; in stating, that a gland when excited by the 
blood, produces its peculiar fluid, just as a muscle when excited 
by some irritating substance, produces motion, we merely offer 
an hypothesis: but even admitting that the process of secre- 
tion is uniformly connected with an excited state of the secre- 
ting organ, it by no means follows that this irritation constitutes 
per se the whole phenomenon of secretion. These remarks 
are sufficient to show, that in the state of health, the hypothesis 



PRELIMINARY OBSERVATIONS. 9 

•of excitement does not afford an explanation of any one vital 
phenomenon, or of the manner in which it is accomplished ; 
that in many cases the existence of this excitement is gratui- 
tously assumed ; and that it is no more capable of explaining 
the phenomena of the healthy state, than its excess or deficien- 
cy is of accounting for those of the state of disease. 

When the augmentation of the natural excitability is attend- 
ed by pain, redness, and swelling, it is termed inflammation. 
This metaphorical expression, invented in the infancy of sci- 
ence, was originally intended to represent a morbid state in 
which the parts affected appeared as if they had been actually 
submitted to the action of fire. As it was originally adopted 
into medical language without having any precise or well de- 
fined idea attached to its signification, either as regards its inti- 
mate nature, the symptoms that indicate its existence, or the 
morbid lesions that characterize its progress, it has now be- 
come so vague in its signification, and in its interpretation so 
arbitrary, that it has really lost all value as a term of science ; 
and, like an old coin, from which the original impression has 
been effaced, should be forthwith withdrawn from circulation, 
as calculated to produce constant error and confusion. In 
fact, inflammation can now only be considered as the expres- 
sion of a complex phenomenon, comprehending under it sev- 
eral other phenomena, which have neither a necessary nor 
even a constant dependance on each other. In this treatise I 
shall omit all description of inflammation, as my object is, not 
to determine whether such or such a group of morbid altera- 
tions should or should not be referred to this term or to another 
term, but to study carefully and attentively each of these alter- 
ations, and to endeavour to investigate their nature, and ascer- 
tain their causes. 



Vol. I. 



10 LESIONS OF CIRCULATION. 



SECTION I. 



LESIONS OF CIRCULATION. 



These lesions may be divided into two principal classes. 
In the first, the quantity of blood in the capillary system is 
preternaturally increased ; while in the second, it is diminished 
below the healthy standard. I shall employ the term Hy- 
peremia to designate the increased quantity of blood, with- 
out any reference to the cause which produces the accumula- 
tion ; and I shall apply the term Ancemia to the diminished 
quantity of the fluids circulating in the capillary vessels. 



CHAPTER I. 

Hypercemia. 

Hyperemia consists in a preternatural accumulation of blood 
in the capillary vessels ; it may be subdivided into the four fol- 
lowing species : — 

1. Active or sthenic hyperemia, produced by irritation. 

2. Passive or asthenic, resulting from diminished tone in the 
capillary vessels. 

3. Mechanical, from an obstacle to the venous circulation. 

4. Cadaveric, or post mortem, being the result of those phys- 
ical and chemical laws, to which all inorganic matter is subject, 
and to which all organized bodies are afto subjected, when the 
vital spark has ceased to animate them. 



LESIONS OP CIRCULATION. 11 

ARTICLE I. 

Active or Sthenic Hypercemia. 

Some local congestions are perfectly compatible with phys- 
iological, or healthy state of the system ; such are the accu- 
mulation of blood in the capillaries of the cheeks, under the 
influence of moral emotions, and the general red state of the 
skin, succeeding to violent exercise. Again, in other cases 
similar congestions, though not actually amounting to disease, 
cannot properly be considered as healthy phenomena. Thus, 
the skin, when exposed to too high, or too low a temperature, 
or to the action of irritating substances, becomes red and con- 
gested ; if these excitants be slight, and their application tran- 
sient, the congestion occasioned by them does not interfere 
with the functions of the part congested, or of the general 
system ; but if the energy of their action be increased, or the 
time of their application prolonged, a true pathological con- 
gestion is gradually formed, attended with pain, and more or 
less of functional derangement, giving rise to different altera- 
tions of nutrition, and calling various morbid sympathies into 
action. 

As the physiological or healthy congestion, as it may be 
termed, passes by insensible gradations into the pathological, 
so this latter state passes insensibly into inflammation. No 
line of demarcation can be drawn between these affections ; 
at least anatomy does not enable us to decide where the one 
ceases, and the other begins ; for instance, under the influence 
of violent passion, the vessels of the conjunctiva become injec- 
ted, and the eyelids grow red ; from the presence of a grain of 
sand precisely similar effects are produced; gradually and 
almost imperceptibly the hyperemia advances from the slight- 
est degree of congestion, in" which only a few vessels are visible 
on the conjunctiva, to the most intense inflammation, when all 
the capillaries are minutely injected, and the conjunctiva 
assumes that uniformly red and tumid appearance termed 
chemosis. Observe also, that the same degree of sanguineous 



12 



LESIONS OF CIRCULATION. 



congestion, which, when occurring in certain organs, occasions 
no alteration of function, or other morbid change, may, in an- 
other tissue or organ, be productive of the most serious conse- 
quences ; how frequently has a simple congestion of the brain 
given rise to an attack of apoplexy ; or a congestion of the 
lungs, to violent and even fatal attacks of dyspnoea. 

The formation of active congestions by no means infers an 
excessive proportion of the general mass of blood circulating 
irt the system. On the contrary, morbid anatomy has clearly 
proved that active hyperaemia occurs as frequently in debilita- 
ted individuals, whose blood is neither abundant in quantity, 
nor rich in quality, as it does in persons of the most plethoric 
temperament; the only apparent difference consisting in the 
local and general symptoms attendant on those congestions. 
The same remark is applicable to the influence of age ; with 
this difference, however, that at different periods of life, the 
seat of the hyperaemia varies as well as the symptoms by 
which it is attended, but at all ages the frequency of the forma- 
tion of active congestion is nearly equal. 

When a hyperaemia is formed in any one organ, it has a 
remarkable tendency to extend and establish itself in other 
parts of the system ; for they are all closely and intimately 
connected. The capillary system, when deranged in any one 
point, is liable to become generally disordered, in which case 
it presents one of two phenomena ; either the original conges- 
lion is propagated to other parts, or, at the same time that one 
or more organs are in a state of hypersemia, some other parts 
of the body (by virtue of a species of compensation established 
between the circulating forces of the capillary system") receive 
less blood than natural, and fall into a state of temporary, or 
even permanent anaemia. Thus when the mucous membrane 
of the stomach is affected with hyperaemia, the cutaneous sur- 
face is sometimes minutely injected, while in other cases it is 
discoloured, and in others again, pale as death : the brain and 
its investing membranes may likewise, in one case, present 
unequivocal marks of violent congestion, and in another be 
found almost exsangueous, and decidedly paler than natural. 



LESIONS OF CIRCULATION. 13 

These pathological observations afford satisfactory explana- 
tions of several morbid phenomena. Thus, for instance, they 
enable us to understand how the delirium, convulsions, and 
other nervous disorders, so frequently supervening during 
attacks of acute gastro-enteritis, and in some cases produced 
by the repetition in the cerebrospinal system, of the conges- 
tion originally formed in the mucous membrane of the intestinal 
canal ; whilst in others, the same symptoms depend on the 
exsangueous state of the nervous system, resulting from the 
circumstance of the blood's accumulation in the organ originally 
congested. 

When a hyperemia is formed in any part of the system, if 
any one organ be at the time in a state of disease, or have pre- 
viously been so, it is that organ, which the hyperaemia has the 
greatest disposition to affect secondarily ; hence it is, that, 
when, from any cause whatever, a local congestion is formed 
in any part of the body, we observe as secondary phenomena, 
palpitations, dyspnoea, haemoptysis, gastric symptoms, haematu- 
ria, or menorrhagia ; according as the heart, lungs, stomach,, 
kidneys, or uterus, are, or have been, diseased, and thus ren- 
dered more susceptible of secondary hyperaemia. 

If, however, previous disease has not predisposed some par- 
ticular organ to attacks of secondary hyperaemia, there is a 
determinate order in the disposition which the different organs- 
possess to be thus affected secondarily. In the first rank 
should be placed, as most disposed to sympathetic congestions,, 
the brain and spinal cord, that portion of the alimentary canal 
situated below the diaphragm, the lungs, the heart, and lastly, 
the cutaneous system. I may also remark, that the organs 
most susceptible of attacks of secondarj^ hyperaemia, are like- 
wise those which, when themselves primarily congested, have 
the strongest disposition to excite the secondary affections of 
other organs. 

There are certain organs never affected with secondary 
hyperaemia, unless when some one particular organ has been 
the seat of the primary affection. The tongue, for instance, 
although, like all other parts of the body, liable to attacks of 



14 LESIONS OF CIRCULATION. 

idiopathic hyperaemia, is never thus affected sympathetically, 
except when the stomach is primarily affected. 

All these circumstances are liable to be considerably modi- 
fied by individual peculiarities of constitution : so that in one 
person the hyperaemia of one organ shall be sympathetically 
communicated to almost every other organ in the body; whilst 
in another the primary hyperaemia shall run its course without 
producing any secondary affection. Several varieties are like- 
wise observed in the form of the secondary hyperaemias, 
which may in general be referred to peculiarities of consti- 
tution. 

When the primary hyperaemia is rapidly developed, those 
secondarily formed are acute likewise ; and, from the rapidity 
of their formation, or the number of parts which they simulta- 
neously affect, they not unfrequently produce as urgent and 
dangerous symptoms, as could result from a much more serious 
organic disease. Thus, the violent dyspnoea, almost threaten- 
ing instant suffocation, which not unfrequently supervenes in 
an acute attack of gastro-enteritis, often leaves no other trace 
of organic derangement, than a slight sanguineous congestion 
of the pulmonary tissue, insufficient to prevent the access of 
air ; in like manner, notwithstanding the host of nervous symp- 
toms, which complicate the progress of almost every attack of 
acute inflammation, the body frequently presents, on examina- 
tion after death, no morbid appearance except a slight conges- 
tion of the vessels of the brain, so slight indeed, that it may in 
some cases fairly be questioned whether this congestion be 
really the cause of the great derangement of the cerebral 
functions, or whether it be not rather an effect resulting from 
the deranged action of the nervous system, especially as all 
those nervous symptoms are sometimes observed when no such 
congestion can be discovered. 

The secondary hypercemias formed in different organs du- 
ring the progress of a chronic disease, may, from their com- 
mencement, assume the chronic character of the original 
hyperaemia ; yet, though their progress be slow, and their 
symptoms insidious, their effects on the system are not the 
less fatal. Sometimes, after having long continued stationary 



LESIONS OP CIRCULATION 15 

in their chronic form, they suddenly burst forth with all the 
violence of an acute and newly-formed disease ; in other cases, 
during the progress of the chronic affection, a new and acute 
hyperemia seizes on an organ which till then had remained 
free from disease. 

This supervention of acute hypersemia is one of the most 
frequent causes of the sudden deaths which occur during the 
progress of various chronic affections ; the lungs and alimen- 
tary canal are the parts most liable, in chronic affections, to 
both these species of hyperemia, namely, aggravation of the 
chronic, and the supervention of the acute form. 

When a secondary hypersemia is formed, one of the follow- 
ing consequences ensues ; either the primary hypersemia is not 
at all affected by it, as is most commonly the case when it is 
violent, or of long standing ; or else it is considerably aggra- 
vated by the newly formed hypersemia reacting upon the en- 
tire system, and more especially on the organ primarily affec- 
ted ; or, lastly, the primary hyperemia ceases altogether when 
the secondary is formed. This, however, seldom happens, 
unless when the primary affection is slight, of small extent, 
and but recently formed : under such circumstances we some- 
times see a hypersemia of the brain take the place of that af- 
fection of the stomach, or a determination artificially produced 
to the surface of the body remove the congestion of some in- 
ternal organ. 

When a patient has lost a large quantity of blood in a short 
space of time ; when, during convalescence frgm a tedious ill- 
ness, he has been long kept on low diet ; or when, after an at- 
tack of acute inflammation, he continues to labour under the 
disease in a chronic form ; whenever, in short, the system has 
been much exhausted without adequate means being taken to 
recruit its losses, it frequently happens that the sensibility of 
the nervous system to impressions is increased, in the same 
proportion as the muscular strength and quantity of blood are 
diminished. Under such circumstances, a hyperemia attend- 
ed with the least degree of pain, may excite the most alarming 
derangement in the functions of the 'nervous system. I have 
seen, in a case of this kind, the bite of a single leech 'produce 



16 



LESIONS OF CIRCULATION. 



symptoms of tetanus ; it is scarcely necessary to add, that the 
application of more powerful irritants, such as cupping glasses, 
blisters, or sinapisms, is still more decidedly contraindicated 
in such cases. To this morbid sensibility of the nervous sys- 
tem must be attributed the injurious effects so frequently ob- 
served to follow the application of revulsives to persons debili- 
tated by copious venesection or protracted abstinence from 
nutritious diet ; not that the hypersemia attended with more or 
less pain, that is produced by the revulsives, directly aggra- 
vates the original hyperemia, but that it produces a violent ef- 
fect upon the nervous system, which in its turn, re-acts upon 
the primary disease, and thus aggravates those symptoms 
which it was intended to relieve. 

This exquisite sensibility of the nervous system is not ex- 
clusively confined to persons labouring under chronic disease, 
or reduced by tedious convalescence ; there are some individ- 
uals in whom this state of the nervous system is constitu- 
tional : they are generally persons of a delicate frame, and 
whose muscular system is imperfectly developed. In such 
•cases, all our attempts to remove local congestions by abstrac- 
tion of blood, only give an increased predominance to the 
nervous symptoms, the repetition of the blood-letting serving 
but to increase the convulsions, coma, delirium, &c. 

Hence it is obvious, that, in our treatment of this class of 
•diseases, the local congestion should not engross our whole at- 
tention ; for the symptoms by which these congestions are at- 
tended not unfrequently depend on some peculiar state of the 
blood or nervous system, which preceded and favoured their 
developement, and consequently it is only by taking all these 
circumstances into account, that our treatment can be either 
judicious or successful. 

From what has been said, appears the importance of study- 
ing the various modifications, which the nervous system may 
undergo in consequence of the formation of even the most 
simple hyperemia : but this system is also liable to be prima- 
rily affected, and, when deranged in its functions, and in the in- 
fluence which it exerts over the other systems, may, in its 
turn, derange the circulation in those systems, and produce in 



LESIONS OF CIRCULATION. 17 

them either temporary or permanent congestions, and thus lay 
the foundation of every species of organic disease. In this 
way an affection at first purely nervous, may subsequently be 
transformed into a hyperemia, and finally produce an exten- 
sive alteration in the texture and organization of the part; 
changes which, we may remark en passant, are by no means 
uniformly characterized by a corresponding alteration of 
symptoms. 

When several hypersemias are formed simultaneously in dif- 
ferent organs, they are sometimes produced one by the other, 
in the manner I have endeavoured to explain ; sometimes 
again their developement, though simultaneous, is independent; 
to these may be added a third class of hyperaemias, which 
have a necessary co-existence, being constantly connected as 
the product of one and the same morbid cause. Thus, in 
measles and scarlatina, two congestions uniformly exist to- 
gether ; one, on the cutaneous surface, the other, in certain 
portions of the mucous membrane. It would be absurd to say 
that, in these diseases, the cutaneous produced the mucous hy- 
peremia, or vice versa : they are both necessary effects of 
one and the same cause ; the manifestation, as it were, of the 
morbid state of the system produced by the introduction of 
the contagious poison. 

This co-existence of several hyperamias appears to be one 
of the most constant effects of the introduction of any delete- 
rious principle into the circulation. It is constantly observed 
in all contagious and infectious diseases, termed typhoid, or 
pestilential ; and likewise in animals that have been made to 
swallow poisons susceptible of absorption, or when putrid sub- 
stances have been injected into their veins. The poison, when 
conveyed into the circulation and mixed with the blood, pro- 
duces three grand effects, which may either exist singly or in 
combination. 1. It alters the blood itself, and renders it to a 
greater or less extent unfitted to support the nutrition and life 
of the different organs. 2. It modifies the functions of the 
nervous centres. 3. It produces irritation, alteration of nutri- 
tion, and hyperaemia, of the organs to which it is distributed 
in its vehicle, the blood. This last effect is however the least 
Vol. I. 4 



18 LESIONS OF CIRCULATION. 

constant of the three, and great functional derangement may 
be produced independently of it. Hence it follows, that if we 
would form a correct and precise idea of the nature and treat- 
ment of those diseases which are produced by miasmata or 
other poisons, we must consider the hyperaemia formed in the 
mucous membrane of the intestines, or elsewhere, as simply 
one of the elementary ingredients of these diseases ; an ingre- 
dient which may be absent and yet the disease be neither less 
rapid in its progress, nor fatal in its termination on that ac- 
count. 

A hyperemia developed under the influence of any irrita- 
ting cause, which produces an unusual determination of blood 
towards some particular organ, may have a very brief dura- 
tion, and disappear completely in a short time after its forma- 
tion. There are several of these acute hyperemias, the du- 
ration of which is circumscribed within certain determinate 
limits, and which uniformly observe the same period of in- 
crease, decline, and final disappearance. In other cases the 
hyperosmia continues for an indefinite period ; this most gene- 
rally occurs when it has not originated in a simple, mechan- 
ical, or chemical cause. Again, in another class of these af- 
fections, the hyperaemia quickly disappears, but has a peculiar 
tendency to re-appear in those organs where it previously 
existed, and, accordingly, does recur at longer or shorter in- 
tervals, sometimes under the influence of manifest causes of 
irritation, and not unfrequently without the apparent agency 
of these causes. 

There are certain forms of hyperaemia both of the acute 
and chronic type, which may be reproduced at pleasure in 
their orignal form and character. Thus, if the skin be ex- 
posed to a high temperature, or irritated by a mechanical 
stimulus, a cutaneous congestion will constantly be produced, 
varying only in its duration and intensity. But there are 
many other forms of hyperaemia which we cannot artificially 
produce; these are generally dependent on some internal 
cause, with the nature of which we are totally unacquainted. 

Sometimes a hyperaemia exists for a considerable period in 
an organ without producing any alteration in its nutrition or 



LESIONS OP CIRCULATION. 19 

secretions, except perhaps some increase or diminution in 
their quantity. In other cases, the organs which have been 
the seat of hyperoemia, undergo various alterations in their nu- 
trition and secretion. Such alterations have this peculiarity, 
that they cannot be produced at pleasure, in the same manner 
as the hyperaemias by which they were preceded ; neither 
can any constant connexion be traced between the nature and 
extent of the organic alteration, and the intensity or duration 
of the preceding hyperoemia. On the contrary, let us vary 
those circumstances as we please, let us increase or diminish 
the intensity of the hyperaemia, protract or shorten its dura- 
tion, we cannot thereby determine the hypertrophy or atrophy, 
the softening or induration of the organ affected, alter its nat- 
ural thickness, produce ulcers on its surface, or modify their 
form, size, or depth ; neither can we, by subjecting the tissue 
of an organ to any determinate degree of irritation, produce 
thereby the developement of any particular accidental pro- 
duction, whether pus, melanosis, or tubercle, &c. The slightest 
hyperaemia is in some cases sufficient to produce all these al- 
terations of nutrition ; whilst in others, the most intense or in- 
definitely protracted hyperaemia may not be followed by any of 
these changes of structure. For these reasons it is, that whilst 
we admit that a determination of blood to the part is a con- 
dition more or less indispensably requisite for the production of 
these alterations, we also maintain, that this local determina- 
tion, or hyperaemia, is not of itself sufficient to produce their 
developement, and that it is perfectly inadequate to account 
for the individual peculiarities of all the various alterations of 
texture ; other conditions, which shall hereafter be considered, 
being indispensably requisite for their production. 

When hyperaemia is followed by the developement of any 
of these various alterations of texture, the antecedent con- 
gestion may either continue, or cease to exist ; this latter case 
is by no means uncommon ; the tissue remains altered, to a 
greater or less extent, in its texture or organization, but no 
longer receives a larger supply of blood than in its healthy 
state, and in some cases receives actually less ; thus the cel- 
lular tissue, when indurated or converted into scirrhus, is of- 



20 LESIONS OF CIRCULATION. 

ten remarkable for its extreme paleness, and thus, in like man- 
ner, the bottom and margins of some intestinal ulcers are 
colourless and exsangueous. 

Congestions of different degrees of intensity and duration 
occasionally assume an intermittent type, and recur, at longer 
or shorter intervals, in the immediate vicinity or in the sub- 
stance of a tissue which has already undergone some chronic 
alteration in its structure and organization. The recurrence 
of those attacks of hyperaemia often renders evident the ex- 
istence of organic lesions, which, during the absence of the 
sanguineous congestion, were either wholly latent, or only re- 
vealed by the most obscure and equivocal symptoms : every 
return of the hyperaemia in such cases invariably aggravates 
the organic disease, and accelerates its progress. The knowl- 
edge of this fact explains the utility of blood-letting in such 
circumstances : the effects of the newly-formed hyperaemia 
are thereby diminished, and although the original organic dis- 
ease be not removed, or even diminished, it is relieved from 
the acute symptoms induced by the supervention of the hy- 
peraemia, and is thus brought back to its original stationary 
condition. 

We must not, however, suppose that local congestions may 
uniformly be removed by blood-letting. It is a fact establish- 
ed by every day's experience, that a hyperaemia may exist 
singly and independent of any organic alteration, and yet 
refuse to yield to either local or general abstractions of blood, 
however copiously employed, or judiciously timed. By the 
employment of blood-letting, the organ congested is relieved 
of a part of its superabundant fluid, the general mass of 
blood in circulation is diminished, and a powerful cause of 
excitation is thus withdrawn from the system ; but neither by 
local nor general bleeding can we remove the unknown cause, 
under the influence of which the hyperaemia was originally 
developed. If, however, this cause be not particularly active 
or violent in its operation, its influence may be considerably 
diminished, or even completely paralyzed by sanguineous ab- 
stractions ; as the blood is thus withdrawn from the seat of ir- 
ritation as often as it tends to accumulate there, and the hy- 



LESIONS OF CIRCULATION. 21 

perEemia is thus prevented from establishing itself in the part. 
But if the exciting cause of the congestion (the thorn of Van 
Helmont) be more violent in its action, we shall in vain at- 
tempt to remove it by blood-letting : though we leave but one 
drop of blood in the body, that drop will, in despite of all 
our bleedings, obey the summons of the irritating cause, and 
fly to the part affected. It is therefore this exciting cause 
which we should endeavour to investigate and counteract, and 
not exclusively confine our attention to the local congestion, 
which is merely an effect, an elementary part of a very com- 
plex phenomenon. The modern Italian school has fully rec- 
ognized the truth of this principle. Convinced of the inef- 
ficacy of blood-letting for the removal of the primary cause 
of congestions, it has endeavoured to discover remedies capa- 
ble of directly combating this cause. How far the contra- 
stimulant medicines really fulfil this indication, it is neither 
consistent with the object of this treatise, nor important for 
our present purpose, to determine ; my only object being to 
establish the primary indication, which should present itself to 
our consideration whenever the hyperemia does not depend 
on a simple irritating cause, externally applied. This indica- 
tion, I repeat it, consists in combating the cause by which the 
congestion was produced. Experience alone will enable us 
to decide whether this indication can be accomplished. We 
may however remark, as connected with this subject, that 
observation has already led us to discover, in cinchona, a 
remedy eminently adapted to prevent the recurrence of inter- 
mitting hyperemias ; and that the writings of Tommassini, 
and his followers, contain many strong facts in favour of the 
contra-stimulant doctrine ; facts which we are by no means 
entitled to reject, because we cannot reconcile them with our 
pre-conceived ideas, and which must eventually be decided by 
the test of experience, and not by their conformity with any 
particular theory. These observations may serve to prove 
that all our therapeutical indications cannot be derived from 
morbid anatomy, and that in many important questions con- 
nected with this subject, no information whatever is to be 
derived from that source. 



22 LESIONS OP CIRCULATION. 

The phenomena of hyperaemia both in the healthy and mor- 
bid states, proved incontestaby that the blood in the capillary 
vessels is withdrawn from under the influence of the heart, and 
that its movements and local determinations are regulated by 
forces inherent in the capillaries themselves. The nervous 
system often modifies the action of these forces, as is exempli- 
fied in the act of blushing. May not the nervous system in 
like manner exert an influence over the production of various 
pathological congestions 1 

The only modification appreciable to our senses which an or- 
gan affected with simple hyperemia undergoes, is the change 
in its colour. This alteration is often produced by an increased 
quantity of blood circulating in the part ; but, on other occa- 
sions, proceeds from the gradual accumulation of this fluid, 
which is retarded in its course, and eventually becomes per- 
fectly stagnant. The following facts will illustrate these as- 
sertions. If we irritate the mesentery of a frog, or any other 
part which is supplied with transparent vessels, and observe 
with a microscope what follows, we shall soon perceive the 
blood flowing from all points, and in every direction, towards 
the part irritated. This experiment was lately repeated by M. 
Broussais among others. " We have ascertained," says he, 
" that the globules of the circulating fluids hurry from all parts 
to converge, even across the veins, towards the point irrita- 
ted by the prick of the pin, and accumulate there so as to form 
a congestion ; and that subsequently those at the circumfer- 
ence can disengage themselves, and take a reverse direction, 
if a new point of irritation be established in the neighbourhood 
of the first. — (Article Irritation, in the Encyclopedic Progres- 
sive, 1st Part, page 143.) 

Dr. Wilson Philip relates, that, in his experiments perform- 
ed on the thighs of frogs, the fins of fishes, and mesentery of 
rabbits, he observed with a microscope, that, on the applica- 
tion of various irritants to these parts, the motion of the glob- 
ules of the blood was invariably retarded, and in some points 
appeared altogether suspended. 

More accurate experiments on this subject have since been 



LESIONS OP CIRCULATION. 23 

undertaken by Hastings, in England, and M. Gendrin in France, 
the results of which may be summed up as follows: 

1. Immediately after the application of various irritating sub- 
stances, chemical or mechanical, to the membrane of a frog's 
foot, the circulation becomes more rapid in the neighbourhood 
of the irritated point, and at the same time the calibre of the 
vessels is considerably diminished, but still no change is per- 
ceptible in the globular appearance of the blood. 

2. At the end of a certain time, when the application of the 
irritating substances is continued, or when their action has 
been so violent that the hyperemia continues after their re- 
moval, other phenomena are observed ; the capillaries become 
gradually dilated, the circulation, which was at first accelera- 
ted, becomes manifestly retarded, the blood assumes a deeper 
colour, and the globules become less distinct, and seem evi- 
dently disposed to coalesce. 

3. At a still later period of the experiment, the circulation 
ceases altogether, and the blood forms a homogeneous mass, 
without any determinate form, or appearance of globules ; its 
colour is changed to a brownish yellow, which gradually as- 
sumes a darker hue. 

4. If the congestion continue, the vessels become still more 
dilated, and the blood, now perfectly stagnant, assumes a dark 
brown or even a black colour ; but if the congestion be dimin- 
ished, the blood gradually recovers its mobility, the globules 
become distinct, the dilated vessels by degrees recover their 
natural calibre, and the circulation resumes its wonted activity. 

5. The application of a second stimulus in some cases 
serves to dissipate the congestion produced by the action of 
the former stimulus. 

The membrane of a frog's foot was moistened with a solu- 
tion of muriate of soda ; in ten minutes after, there was a re- 
markable dilatation of the vessels, the circulation was retard- 
ed, the blood, deprived of its globular appearance, seemed 
disposed to coagulate, and its colour was changed to a dark 
red. Some alcohol was then poured on the part ; in five min- 
utes after its application, the venous trunks were contracted, 
the blood circulated more rapidly, and resumed its globular 



24 LESIONS OP CIRCULATION. 

appearance and natural colour. When five minutes more had 
elapsed, the same changes were observed in the smaller ves- 
sels ; some of them however continued dilated, the blood re- 
tained its deep red colour, presented no traces of its globular 
composition, and circulated much more slowly than in the 
veins. The blood which passed from these dilated capillaries 
into the venous trunks, was remarkably different in appear- 
ance from that which was poured into them from the sound 
capillary vessels. It was deeply coloured, and seemed to con- 
tain several small irregular flocculi, not unlike the torn frag- 
ments of a coagulum of blood : these flocculi disappeared after 
having circulated for some time in the larger veins. 

G. So long as the blood circulates with increased rapidity, 
no other change is oberved in the part irritated than this in- 
creased velocity of its motion ; it coincides with the contrac- 
tion of the vessels, and is in fact a necessary consequence of 
it. But when, at a later period of the experiment, the circu- 
lation becomes retarded, a new series of phenomena is pre- 
sented; serous or purulent fluids make their appearance in the 
part congested, and at the same time, the tissues are softened. 
At a later period still, when the circulation is completely sus- 
pended, and the blood assumes a deep brown tinge, all the 
parts in which these phenomena occur, become more and 
more soft and flaccid, are transformed into a gangrenous mass, 
and finally separate in the form of an eschar, from the adjoin- 
ing sound parts. 

It follows from these experiments that we must admit the 
existence of several degrees of hypersemia, both as regards the 
state of the blood itself, and of the capillary vessels of the part 
affected. The first degree of hyperasmia is that in which the 
vessels are contracted, and the circulation consequently ac- 
celerated, both because the vessels then act more energetical- 
ly on their contents, and because of the fulfilment of an estab- 
lished principle in hydraulics ; namely, that a fluid passing in 
full stream from larger into smaller tubes is thereby accelera- 
ted in its motion. 

The second degree of hypersemia succeeds to the first : the 
vessels dilate, the blood circulates more slowly, its particles 



LESIONS OF CIRCULATION. 25 

tend to coalesce, and the whole mass seems disposed to coag- 
ulate. From the condensation and unusal accumulation of the 
blood, the part affected assumes a deep red colour, which sub- 
sequently changes to a brown shade, as the circulation of the 
part becomes more completely suspended. 

In the third and last degree of hyperaemia, the blood be- 
comes perfectly stagnant, and the seat of the hypergemia as- 
sumes a yet deeper shade of brown, and finally becomes quite 
black. 

These successive alterations in the colour of the blood, aris- 
ing from its retarded motion, and subsequent stagnation, were 
long since ascertained by the experiments of Hunter, who like- 
wise observed that whenever arterial blood is stopped or even 
retarded in its course, it assumes the dark colour of venous 
blood. The following experiment is illustrative of this fact. 
If a portion of artery be intercepted between two ligatures, 
and if, after some time, an incision be made into the intercept- 
ed part, the blood which issues will be found black and per- 
fectly similar to venous blood. The blood which flows from a 
wounded artery and is effused into the surrounding cellular 
tissue, becomes in like manner almost completely black on 
coagulation. This dark colour of the blood is also observed 
in such cerebral apoplexies as are not immediately fatal ; in 
pulmonary apoplexy, and likewise in those cases where the 
colouring matter of the blood being deposited in the tissues, 
gradually acquires from its prolonged stagnation in the part, 
that uniform black colour which has received the name of mel- 
anosis. 

If, then, it be established, that the blood circulates more 
slowly, or even ceases altogether to circulate, in parts affected 
with hyperaemia in the second or third degree ; and that the 
blood uniformly assumes a darker shade whenever its motion 
is retarded or suspended ; we are, I conceive, warranted in 
attributing to these causes, the slate-coloured, brown, or black 
colour which parts affected with hyperaemia not unfrequently 
present. If we consider attentively the circumstances in which 
such appearances are usually observed, we shall find them ref- 
erable to one of two classes : 1st, where a violent congestion 

Vol. I. 5 



26 LESIONS OF CIRCULATION. 

is rapidly formed ; as when the mucous membrane of the 
stomach is exposed to the action of a corrosive poison, or the 
cutaneous tissue to an extreme elevation or depression of tem- 
perature ; 2d, where a hyperaemia is formed slowly, and grad- 
ually, and exists for a considerable time in a chronic form. 
Now it is precisely in these cases, that, according to the ex- 
periments above cited, the circulation is retarded, or suspend- 
ed. In the first case, when a violent hyperaemia has been sud- 
denly developed, the circulation must be retarded, and if the 
hyperasmia be sufficiently violent, it will be suspended alto- 
gether ; if this suspension of the circulation be prolonged, and 
the stagnation complete, the consequence is, that the part be- 
ing gorged with blood, which is no longer renewed, and which 
soon becomes unfitted to maintain nutrition and life, must ne- 
cessarily die, and present the phenomena of gangrene, just as 
in the experiments of Hastings above recorded ; so that in 
these cases the black colour of the part announces the stagna- 
tion of the blood, and its stagnation, if prolonged, necessarily 
produces the death of the part. Such, in my opinion, is the 
mode of production of that species of gangrene, which is gen- 
erally attributed to excess of inflammation. 

In the second case, when a chronic hyperaemia is slowly 
formed, the circulation is not completely suspended ; it is only 
retarded in proportion to the dilatation of the capillaries, and 
accordingly, in the chronic hyperaemia, we do not observe the 
same deep black colour, but a slate-coloured, grey, or brown 
shade, similar to that which, in several of the experiments al- 
ready cited, was observed to depend on the retarded motion 
of the capillary circulation. 

We occasionally observe, that parts which had at some for- 
mer period suffered an attack of hyperaemia, although they 
may have been subsequently exempt from any recurrence of 
the affection, still continue to present an unnatural colour, eith- 
er violet, yellow, grey, slate-coloured, brown, or even black. 
These different shades of colour are often met with, on the 
sites of old herpetic eruptions, and of ulcers long since healed. 
The continuance of these different colours after the tissue 
affected has in all other respects recovered its natural appear- 



LESIONS OF CIRCULATION. 27 

ancc, seems to depend on the dilatation of the vessels continu- 
ing after the complete removal of the irritation, which neces- 
sarily produces a retardation in the motion of the blood con- 
tained in the capillaries, and consequently an alteration in its 
colour. . 

Let us now endeavour to investigate the nature of those 
forces under the influence of which the capillary vessels, that 
were at first contracted, become subsequently dilated. Does 
the force by which the blood is impelled from all parts towards 
the seat of irritation, contrary to its natural course and the 
laws of gravity, reside in the blood itself? Is the dilatation of 
the vessels a passive result of the mechanical distention which 
they undergo from the unusual afflux and accumulation of 
blood ? or does it rather proceed from the diminished elastici- 
ty of their parietes, resulting from some alteration in their text- 
ure ? or, lastly, does it arise from an expansive force residing 
in the coats of the vessels ; a force analogous to that which 
appears to exist in the parietes of the heart (whose dilatation 
is decidedly not a passive phenomenon) and in the erectile tis- 
sues? 

The analogy is perhaps stronger than might at first be ex- 
pected, between the phenomena which occur in an organ af- 
fected with active hyperemia, and those which take place in a 
tissue in a state of erection. One material difference may 
however be noticed, namely, that in the erectile tissue the parts 
are naturally so constructed, and disposed, as to admit of a 
sudden accumulation of blood under the influence of certain 
physiological conditions ; whereas the natural texture of an 
organ not erectile must first undergo some modification, before 
it is capable of receiving and retaining more blood than it is 
ordinarily supplied with ; hence arise various derangements 
of function in the organ congested, and alterations in its nutri- 
tion, secretion, and sympathetic relations with other organs. 

As these considerations are not so much matters of fact as 
of speculation, I shall not urge them further at present, and 
shall conclude this part of my subject with the observation, 
that even if all hyperaemias are identical at their commence- 
ment, if they all uniformly consist in an unusual afflux of blood 



28 LESIONS OF CIRCULATION. 

towards some point, accompanied by contraction of the ves- 
sels, and increased rapidity in the local circulation ; if, I say, 
in this first stage of their existence, they are simply the phe- 
nomena of the healthy condition of the part in a state of exag- 
geration, a second period sooner or later succeeds, in which 
the phenomena can no longer be considered as such ; at this 
period commences the developement of the different alter- 
ations of texture, and of the various morbid secretions, which 
we cannot at all conceive to be produced by the simple aug- 
mentation of organic action. 

The hyperemia, instead of being confined to a simple organ, 
may exist at the same time in every organ of the body ; the 
general capillary system is then overloaded with blood, and the 
whole system is said to be in a state of plethora or ■polyae.mia. 
I shall not enter into a detail of the symptoms which charac- 
terize this state, the essential character of which seems to con- 
sist in the formation of a greater quantity of blood than is ne- 
cessary for the purposes of nutrition and secretion. There are 
some individuals who, according to a common observation, 
naturally make a greater quantity of blood than others ; in 
general those persons who live high and make but little exer- 
tion either mental or corporeal, are most liable to this affec- 
tion. It has been said, but without the slightest proof being 
adduced in support of the assertion, that an appearance of 
plethora has been produced in some individuals by an inordi- 
nate expansibility of the blood. 

When the blood-vessels contain a greater proportion of the 
nutritive fluid than is necessary to supply the demands of the 
different organs, the superabundant quantity becomes a per- 
manent source of excitation to the solids, and at the same time 
the blood has a remarkable tendency to accumulate in differ- 
ent organs, so that in such cases, the whole system is in a gen- 
eral state of excitation, and some of the organs may become 
the seats of local congestions of various degrees of duration 
and intensity ; indeed the phenomena which result from the 
plethoric diathesis cannot properly be termed morbid, unless 
when some such local congestion is formed. Sometimes the 
brain is the seat of this congestion, and then follow the various 



LESIONS OF CIRCULATION. 29 

symptoms of cerebral disease, giddiness, headach, drowsiness, 
alteration of the sensorial and intellectual faculties, &c, which 
may be so violent as to produce death, and yet leave no trace 
of disease, except a little more blood than usual in the cere- 
bral vessels. Sometimes the congestion more particularly af- 
fects the pulmonary organs ; the dyspnoea which accompanies 
this form of the disease arises from an unusual quantity of 
blood being transmitted through the lungs, which necessarily 
requires a corresponding quantity of air to fit it for the pur- 
poses of the general circulation ; it is this want of proportion, 
between the blood which requires to be aerated, and the 
quantity of air inspired for that purpose, which produces the 
dyspnoea. In other cases, the complication of palpitations with 
various degrees of dyspnoea, prove that the heart has become 
the seat of congestion. 

In some instances the different mucous membranes are the 
parts which are more especially affected ; the habitual injection 
of the cutaneous surface so constantly observed in plethoric 
individuals, would lead us to infer the probable existence of a 
similar state of the internal tegumentary membranes, of the 
gastro-intestinal membrane for instance, thus producing all the 
phenomena of impaired digestion, in the same manner as the 
functions of the brain become deranged from the accumulation 
of blood in the cerebral capillaries. The mucous membrane 
when thus congested, not unfrequently suffers repeated attacks 
of sanguineous exhalations more or less abundant ; and it is by 
no means uncommon to see different portions of this membrane 
successively affected, and giving rise accordingly to alternate 
attacks of epistaxis, hasmoptysis, . hsematuria, menorrhagia, 
hasmorrhoidal flux, &c. 

Under the influence of this state of general hyperemia, 
serous effusions unattended with pain or other symptoms of 
inflammation, take place into the cellular tissue and into the 
different cavities lined with serous membranes, especially the 
abdomen. It appears to me highly probable that these drop- 
sical effusions, which are generally denominated active, are 
simply the mechanical result of the over-distention of the 
vessels, which allow the serous portion of the fluid by which 



30 LESIONS OF CIRCULATION. 

they are over-distended, to transude through the parietes of 
their capillary ramifications. In confirmation of this view of 
the subject, I may cite the observation, that if a large quantity of 
water be injected into the veins of an animal, without having first 
withdrawn blood from his system, serous effusions are quickly 
formed ; whereas, if the mass of blood be diminished by vene- 
section before the water be injected, that fluid is gradually and 
almost imperceptibly eliminated. Besides, we know from 
actual experience, that those dropsies usually termed active, 
which are combined with a state of general hyperemia of the 
system, are constantly relieved, and not unfrequently altogether 
removed, by the use of the lancet. 

When, in consequence of an universal hyperemia, each 
solid particle of the system becomes over-excited by its exces- 
sive supply of blood, and when this state of general excitation 
is carried to a considerable extent, the sympathies which asso- 
ciate the different organs, are rendered more active, and an 
inordinate reaction ensues ; in consequence of which the func- 
tions of the nervous system become disordered, the temperature 
of the surface elevated, the different secretions variously modi- 
fied, the pulse augmented in strength and frequency, and in 
short all the phenomena of fever are fully developed. This 
fever once formed may be ephemeral, or may continue for 
several days. Sometimes it presents no dangerous symptom 
during its entire course, thus constituting the simple continued 
fever of authors. In other circumstances the intensity of the 
reaction of the different organs gives rise to more alarming 
symptoms, and various nervous phenomena make their appear- 
ance, attended with sudden prostration of strength, and false 
adynamia. Lastly,, it not unfrequently happens that some one 
organ becomes more especially affected, and so the disease, 
which, in the commencement, was universal, is subsequently 
converted into a local affection. 

The morbid state which I have now described, and to which 
may be referred some of the species of continued fever de- 
scribed by the older nosologists, may terminate in recovery or 
death. When the termination is favourable, the symptoms 
gradually improve, as the super-abundant quantity of blood, 



LESIONS OF CIRCULATION. 31 

the original source of all the accidents, is diminished by absti- 
nence and blood-letting. When death ensues, the post mortem 
examination generally exhibits traces of a well-marked inflam- 
mation of one or more organs ; this inflammation seems to have 
taken place subsequently to the commencement of the febrile 
paroxysm, at least the symptoms would lead us to this conclu- 
sion. But on other occasions no trace of inflammation can be 
discovered, and the only morbid appearance consists in a sim- 
ple accumulation of blood in the capillaries of different organs, 
their texture remaining perfectly unaltered. These slight 
congestions, affecting simultaneously several organs, may, by 
the various morbid sympathies which they excite, produce as 
violent and formidable symptoms as the most serious organic 
lesion of any individual organ. In such cases where are we to 
assign the origin of the disease ? Wherever the blood is dis- 
tributed, there derangement of function is found. In the blood, 
then, indisputably resides the first cause of the disease ; the 
lesion of the solids is only a secondary affection, but may not- 
withstanding become, during the progress of the disease, the 
predominant affection, and give rise to many and formidable 
accidents. 



ARTICLE II. 

Asthenic Hypercemia. 

A violet colour may frequently be observed on the anterior 
surface of the legs and feet of persons advanced in life, without 
any assignable cause but the diminished energy of the capillary 
circulation. It appears that in these cases the blood having 
arrived at the termination of the arterial branches, where its 
circulation is maintained by the united influence of the heart's 
action and the tonic force of the capillary vessels, has a ten- 
dency to stagnate whenever these forces are diminished. This 
diminution of the circulating forces is principally felt in those 
arterial ramifications farthest removed from the heart, and 



32 LESIONS OF CIRCULATION. 

where the blood in its passage from the capillaries into the 
larger veins has to overcome the force of gravitation. The 
influence of this cause is clearly proved by the fact, that simply 
placing the limb in the horizontal position is in most cases suf- 
ficient to remove the appearance of congestion. 

In some of these cases, the blood which passes from the 
arteries into the capillaries of the feet, returns but in small 
quantities by the veins, and gradually accumulates to such an 
extent, as to oppose an effectual obstacle to the arrival of a 
fresh supply of arterial blood from the heart. The blood thus 
accumulated in the capillaries, being arrested in its course, 
coagulates, and obliterates the cavities of the vessels, so that 
their calibre is filled with coagulated blood, which is often 
found advancing towards organization. The same series of 
phenomena must then ensue, as when the blood was accumu- 
lated in the capillary vessels under the influence of an acute 
hyperaemia, (see the preceding article,) namely, the blood 
becomes black, is no longer adapted to maintain the life of the 
part, and gangrene supervenes. 

Such is the true pathology of the disease termed gangrena 
senilis. There is at first, in the most dependent portion of the 
limb, passive stagnation of blood in the capillaries, and, in con- 
sequence of the mechanical obstacle to the circulation thus 
formed, coagulation of the blood which arrives by the arteries, 
and, as a necessary consequence of these two phenomena, 
gangrene of the feet and legs.* 

The existence of a true asthenic hyperaemia appears to me 
fully established in the case just described, and this may serve 
to prove how erroneous is the conclusion that, if a part be 
more red than natural, it must necessarily be affected with 
active hyperaemia. It is evident that by covering the livid 
part with emollient poultices we should but aggravate the dis- 
ease, and that the only practice likely to prove beneficial in 



* M. Cruveilhier succeeded in producing gangrene of a limb, by injecting 
the minute arterial ramifications of the part with quicksilver. 



LESIONS OF CIRCULATION. 33 

such cases, consists in applying active stimulants to arouse the 
languid circulation of the capillaries. 

Before proceeding to consider whether the redness obser- 
vable in the internal organs may not, in like manner, occasion- 
ally depend upon passive congestion, it may be worth while 
to examine whether other instances might not be brought for- 
ward to illustrate the existence of asthenic hyperaemia in the 
surface of the body ; especially as some modern pathologists 
have thought proper to deny its existence altogether. 

During the course of certain acute diseases, in which the 
functions of the nervous system are more or less seriously de- 
ranged, the application of the slightest irritation to the cutane- 
ous surface is sufficient to convert the red colour, which the 
parts previously presented, into a violet, brown, or even black 
colour ; and thus substitute gangrene in the place of a simple 
sanguineous congestion. No doubt in such cases the gangrene 
was preceded by active hyperaemia : but does it necessarily 
follow from thence that the gangrene was produced by excess 
of irritation ? To me it appears much more probable, that, in 
consequence of some peculiar modifications of the nervous 
influence, the blood, after accumulating for some time in a part 
of the cutaneous surface, at length ceased to move, and be- 
came perfectly stagnant, because the capillary vessels being 
deprived of the nervous influence which should regulate their 
functions, could no longer expel their contents ; and in this 
way a passive hyperaemia was formed where an active hyper- 
aemia had previously existed. The frequency of gangrene in 
these cases is directly proportional to the alteration of the 
nervous influence. Its occurrence is most common in the 
various epidemics of the plague and typhus fever, in which its 
appearance is not necessarily preceded by increased vascular 
action, or active hyperaemia; for it constantly happens that 
several spots in the cutaneous surface turn spontaneously red, 
then brown, and finally form a gangrenous eschar. 

By this method of accounting for the formation of gangrene, 

the application of therapeutic agents is considerably simplified, 

and additional confirmation is afforded to the efficacy of the 

old established practice of covering with powdered cinchona, 

Vol. I. 6 



34 LESIONS OF CIRCULATION. 

&c, the red patches, excoriations, and sores, which occur 
during the progress of severe fevers, whenever their surfaces 
present a grey or brownish colour. Thus we see that when 
a part is threatened with gangrene, the inflammatory action 
which ushered in the disease should not exclusively engage 
our attention, as there are various other matters equally im- 
portant to be taken into consideration, in order that we may 
form a correct idea of the phenomena of this formidable affec- 
tion, and adopt the most appropriate method of treating it. 
We have another example of the asthenic hyperemia on the 
surface of those old ulcers and sores which shoot up red, flab- 
by, fungous granulations, composed of loose cellular tissue 
gorged with blood, which are speedily removed by the appli- 
cation of topical stimulants. These fungous productions occur 
most frequently in those parts of the cutaneous surface, which 
have been long exposed to irritation, in debilitated exsangue- 
ous individuals, whose circulation is languid, and who have a 
manifest disposition to scurvy. 

Asthenic hyperasmia also occurs in the external mucous 
membranes, either as a primitive affection, or consecutively to 
an attack of active hyperaemia. Thus after the mucous mem- 
brane of the eye has been for some time affected with an ac- 
tive congestion of greater or less intensity, three cases may 
present themselves : 1. The redness of the conjunctiva may 
disappear altogether. 2. It may continue indefinitely, though 
in a less violent degree ; but the ill effects which are constant- 
ly produced by the application of stimulants, prove that the 
congestion is still kept up, under the influence of some irrita- 
tion. 3. There are other cases in which the capillaries of the 
conjunctiva continue minutely injected, and appear dilated and 
varicose ; but their colour is a deeper shade of brown, is rather 
increased than diminished by emollient applications, and often 
disappears altogether under the use of stimulants. How then 
is the action of these irritating agents to be explained ? Sim- 
ply thus ; they stimulate the relaxed debilitated vessels of the 
conjunctiva, restore their natural tone and elasticity, enable 
them to propel the blood as quickly as they receive it, and 
thus dissipate the appearance of increased vascularity. 



LESIONS OF CIRCULATION. 35 

In this last case then, the hyperaemia, was asthenic, while 
in the other two it was sthenic ; thus we see that, when we 
propose treating a congestion on the stimulant plan, the ques- 
tion to determine is, not whether the hyperaemia is acute or 
chronic, but whether it is sthenic or asthenic. It matters 
little whether the blood flows towards the part congested for 
a single day or for a series of months ; if irritation be the cause, 
the application of any description of stimulus will be injurious; 
if, on the contrary the congestion be kept up solely by the 
passive dilatation of the vessels, stimulants will then act bene- 
ficially, by restoring to the over-distended vessels the power 
of reacting on their contents. 

The mucous membrane which lines the mouth presents, in 
scorbutic individuals, another example of asthenic hyperemia; 
for in addition to the alteration which the blood undergoes in 
such persons, there is likewise a diminution of energy through- 
out the whole system of the capillary circulation, and hence 
results the congestion by stagnation, in those parts which are 
naturally the most abundantly supplied with blood ; as the 
gums, the spleen, and other parenchymatous organs. This 
mode of explaining these phenomena enables us to understand 
how the passive congestions which so frequently occur in scor- 
butic individuals are successfully treated by the local and gen- 
eral employment of tonics. 

In the several cases just enumerated, the appearance of the 
congestion, the circumstances attendant on its formation, but 
more especially the nature of the thereapeutic agents found 
most efficacious in removing it, lead us to conclude that the 
hyperemia was not the result of irritation. We will assume, 
then, as an established fact, that asthenic hyperemias may be 
formed in those parts of the body situated externally ; which 
constitutes a strong presumption in favour of the possibility of 
their formation in the organs situated internally. Let us ex- 
amine how far this supposition is supported by observation. 

I shall commence with the lungs, which, as is well known, 
receive and transmit through their capillaries (for the purpose 
of aeration) the whole mass of blood which is subsequently dis- 
tributed to the different parts of the body. Perhaps there is 



36 LESIONS OF CIRCULATION. 

no one organ in the animal ceconomy, which is so frequently 
affected with active hyperemia in its different forms and de- 
grees ; but this viscus is likewise susceptible of other forms of 
congestion, the asthenic nature of which appears to me satis- 
factorily established. In the first place, I presume that few 
persons will refuse to admit as an instance of asthenic hyper- 
emia, those sanguineous congestions of the pulmonary paren- 
chyma which so constantly occur during the last moments of 
existence. It is evident that, in such cases, the blood driven 
into the ultimate branches of the pulmonary artery, or into the 
minute ramifications of the pulmonary veins, no longer re- 
ceives from these vessels the impulse which should propel it 
onwards to the left side of the heart ; the lungs become in 
consequence gorged with blood, just as in those animals in 
which the eighth pair of nerves has been divided, or in per- 
sons labouring under an apoplectic fit. In all these cases the 
activity of the capillary circulation is diminished, in conse- 
quence of the diminished energy of the nervous influence ; 
and yet the morbid appearances found on dissection are pre- 
cisely the same as are presented after inflammation ; namely, 
a great accumulation of blood in the vessels, and in the small 
bronchial tubes a quantity of serous fluid mechanically filtered 
from the blood. We should learn from this example not to 
place too implicit reliance on the anatomical characters of a 
morbid lesion, as a criterion for deciding the nature of the dis- 
ease. 

But this passive congestion of the lung is not confined to the 
last moments of the mortal agony. Can we not, for instance, 
detect its existence in certain cases of convalescence from 
acute pneumonia, in which a slight degree of dyspnoaa re- 
mains, and a " rale crepitant " continues audible, although the 
thorax has resumed its natural sound on percussion? No 
doubt these symptoms often depend on a trace of the original 
inflammation still lurking in the part, and not yet subdued ; 
but I have also seen similar cases, in which the pulmonary 
congestion continued for a length of time stationary, notwith- 
standing the employment of antiphlogistics and revulsives, and 



LESIONS OF CIRCULATION. 37 

yet yielded immediately to the use of tonics, such as the de- 
coction of polygala or cinchona. 

Is it not reasonable to conclude that those substances, when 
absorbed and carried into the circulation, produced the reso- 
lution of the pulmonary congestion, either by directly stimula- 
ting the coats of the pulmonary vessels in their passage through 
them, or else by exciting the centres of the nervous system, 
and restoring their natural influence over the lung and its cir- 
culation ? If it has been proved that the asthenic may take the 
place of the sthenic hypersemia, when affecting the conjunctiva 
or the skin, why may not the same changes take place in the 
mucous membrane of the lungs ? The success of the tonic 
treatment in both cases argues strongly in favour of this sup- 
position. 

At a certain period of long protracted diseases, when the 
patients lie constantly on their backs, even though the lungs 
may have presented no previous symptom of disease, the pul- 
monary circulation becomes impeded, and the lung itself more 
or less congested, and after death is found gorged with blood 
and serum. I do not think that this congestion, which has 
been aptly termed by M. Lerminier the obstruction from po- 
sition, (engouement de position,) can reasonably be attributed to- 
any process of irritation ; it is, in fact, an asthenic hyperemia 
precisely similar to that, which, in individuals exhausted by 
protracted illness, is produced in any part of the skin that hap- 
pens to be placed in a dependent position. If we suppose the 
part to be maintained in this position, the weakened capillaries 
will no longer act with sufficient energy to overcome the force 
of gravity of the blood, will gradually yield to the dilating force 
of their contents, and will ultimately be converted into mere 
passive tubes, which will discharge only that portion of their 
contents which they cannot retain. 

I am also disposed to think that in some other conditions of 
the ceconomy, such as severe scorbutic affections, the lungs 
may be passively congested as well as the gums and certain 
portions of the cutaneous surface. This at least I am sure of, 
that in four cases of severe scurvy, two of whom I attended 
at the Hopital des Enfans, a third at La Charite, and the 



38 LESIONS OF CIRCULATION. 

fourth in private, all of whom were affected with constant 
dyspnoea unattended with other symptoms of pulmonary dis- 
ease, I found, at the post mortem examinations, the lungs not 
altered in texture, but gorged with an enormous quantity of 
blood, remarkable for its extreme tenuity and bright rose col- 
our, and presenting the appearance of water slightly tinged 
with red. A fluid precisely similar .in appearance was effused 
into the cavities of the different articulations ; the spleen and 
liver were also filled with it : in two of these cases several 
ecchymoses were found between the tunics of the alimentary 
canal, and in all of them several patches of the subcutaneous 
and intermuscular cellular tissue, as well as of the skin itself, 
were infiltrated with blood. 

Have we not, again, instances of asthenic hyperemia affect- 
ing the mucous membrane of the bronchia, in persons labour- 
ing under chronic catarrh, whose symptoms are relieved or 
altogether removed by the use of tonic medicines ? On the 
contrary, in those individuals labouring under the same dis- 
ease, whose catarrhal symptoms, however chronic, are uni- 
formly aggravated by the use of stimulants, the sthenic char- 
acter of the original hyperemia would seem to be still pre- 
served. 

If, then, direct proofs, and powerful analogies, coincide to 
prove the existence of asthenic hyperaemia in the interior as 
well as on the surface of the body, whether existing as a 
primary affection, or as consecutive to sthenic hyperaemia, we 
cannot reasonably withhold our assent from the proposition, 
that several of the red patches found after death in the mu- 
cous membrane of the stomach and intestines, are simply the 
result of passive congestions formed during the life of the in- 
dividual. 

Thus we find that in every organ two species of hyperaemia 
may occur, (we have not yet taken into consideration a third 
species, namely, the mechanical,) the one active or sthenic, 
produced by the increased afflux and accumulation of blood 
caused by some irritation ; the other passive or asthenic, the 
result of the diminished tone of the capillary vessels, which no 
longer possess the force requisite for propelling the blood as 



LESIONS OF CIRCULATION. 39 

fast as they receive it. It sometimes happens that the blood 
remains accumulated in an organ, long after the irritation 
which first produced its afflux and accumulation, has subsi- 
ded. This, which is a case of consecutive asthenic hyperemia, 
seems to depend principally, if not entirely on the permanent 
dilatation of the capillary vessels. The sthenic hyperaemia is 
one of the degrees of what is generally termed inflammation ; 
one of the elements of that complex phenomenon. The as- 
thenic hyperaemia is essentially different both in its nature and 
in the causes which produce it, and comes nearer that state of 
parts which was long designated by the term asthenic inflam- 
mation. The origin of this expression may be traced to the 
fact long since observed, that certain morbid states were most 
successfully treated by stimulants, whilst others, precisely sim- 
ilar in their anatomical characters, could only be subdued by 
the employment of antiphlogistics properly so called. The 
expression should now no longer be retained, for the words 
asthenic inflammation imply a manifest contradiction of terms. 



ARTICLE III. 

Mechanical Hyperemia. 

This term may be applied to the sanguineous congestion 
formed during life, wherever an impediment to the free course 
of the venous circulation presents a mechanical obstacle to the 
return of the blood from the capillaries towards the heart. 

The principal causes which produce mechanical hyperaemia 
are as follow : 

1. Simple gravitation, when exerted in parts which are not 
naturally subjected to it, and are consequently less prepared 
to resist its influence. Thus, the face quickly becomes con- 
gested when the head is held for some time in the dependent 
position. This cause produces hyperaemia more promptly, if 
the circulating forces have been previously debilitated, as has 



40 LESIONS OF CIRCULATION. 

already been explained in the preceding article. In such 
cases the hypersemia may continue after the mechanical cause, 
which first produced it, has ceased to operate. 

2. A defect of proportion between the respective capacities 
of the cavities of the heart, or even a simple alteration in 
their natural dimensions. In this case the blood, brought by 
the venae cavse or by the pulmonary veins to the central or- 
gan of the circulation, encounters an obstacle to its entrance, 
and consequently tends to stagnate in the large venous trunks 
which communicate with the heart ; next, in the lesser veins 
which by their union form these trunks ; and, lastly, in the 
different capillary networks. The parts most abundantly sup- 
plied with blood-vessels, such as the lungs, liver, digestive 
canal, and certain portions of the skin, especially of the face, 
are in such cases most liable to congestion. It is scarcely ne- 
cessary to remark that this hypersemia must exist simultane- 
ously in several organs, and that all the capillaries of the body 
may be more or less over-distended. 

3. The compression or obliteration of a venous trunk. This 
necessarily produces congestion of the capillary vessels which 
pour their blood into this vessel, whenever this circulation is 
not carried on by collateral branches. Thus the application of 
a ligature round the trunk of the vena portce necessarily pro- 
duces congestion of the mucous membrane of the intestines. 

4. Any obstacle to the passage of the blood through the 
capillary vessels which are formed by the subdivision of a 
trunk carrying venous blood. Such, for instance, are the 
capillaries in the liver resulting from the subdivision of the 
vena porta?, and in the lungs from the ramifications of the pul- 
monary artery. Accordingly, we observe the mechanical con- 
gestion of all those parts which return their venous blood by 
the vena portaa, whenever an obstacle to the circulation exists 
in the parenchyma of the liver ; and hence, in like manner, 
proceeds the general hyperemia of the whole body, which 
follows the sudden interruption of the pulmonary circulation, 
as is exemplified in all cases of death from asphyxia. In such 
instances the face is swollen and livid, the eyes as if starting 
from their orbits, the lips purple, the tongue tumid and pro- 



LESIONS OF CIRCULATION. 41 

jecting from the mouth, and the whole cutaneous system in- 
jected with dark venous blood, and presenting a mottled ap- 
pearance. When the body is examined, the lungs are found 
gorged with blood, as are also the right auricle and ventricle, 
as well as the whole venous system ; whilst the left side of 
the heart and the arteries are remarkably empty. When, 
however, the pulmonary circulation is gradually and slowly 
obstructed, the sanguineous congestion which results, is by no 
means so great as when the obstacle is suddenly formed ; the 
cause of which appears to be, that in proportion as the lungs 
gradually admit a less quantity of blood to circulate through 
them, the absolute quantity of blood in the whole system is 
also diminished, the sanguification becoming constantly more 
and more imperfect ; this is strikingly illustrated in pulmonary 
consumption. 

Mechanical hypersemia produces in the parts where it ex- 
ists, several anatomical alterations, which may be referred to 
the three following classes : 1, changes of colour ; 2, morbid 
exhalations ; 3, modifications of the size and consistence of 
the part affected. 

The alteration of colour which accompanies every mechan- 
ical hypersemia, results exclusively from the accumulation of 
blood in the capillary vessels, and may be either bright red, 
violet, or brown, more or less deep in shade. In the first stage 
of this affection, the congestion is confined to the veins of con- 
siderable calibre ; the transparency of the tissues is not af- 
fected, nor is their natural whiteness altered, except where 
those veins apparently varicose are distributed. In a second 
stage, veins of a less calibre become congested, and if the tis- 
sue affected be membranous, several minute vessels are ob- 
served ramifying in an arborescent form on its surface ; if the 
seat of the hypersemia be a parenchymatous organ, an unusual 
quantity of blood issues from the part when pressed, or simply 
divided. Thus, in such a case, the brain, when sliced, pre- 
sents numerous red points, which are nothing else than the 
divided orifices of the congested vessels ; while a section of 
the liver presents an uniform red appearance, &c. Lastly, in 
several parts of the cellular tissue, which is interposed between 
Vol. I. 7 



42 LESIONS OF CIRCULATION. 

the different organs or parts of the same organ, a number of 
minute vessels filled with blood are seen ramifying in every 
direction ; in such cases, the cellular sheath of the arteries is 
sometimes beautifully injected, and the vasa vasorum admirably 
displayed. In a third degree, the most minute vessels become 
injected, and are so distended that they appear literally to 
touch and crowd each other ; the tissue thus mechanically con- 
gested presents an uniform red, brown, or even black colour. 

When the mechanical hypersemia is carried to a certain ex- 
tent, other phenomena may arise as its consequence. Thus, 
the serous portion of the blood, or even pure blood, may es- 
cape from the over-distended vessels, just as water or any 
other liquid transudes through the permeable sides of a vessel 
in which it suffers compression. To this source are to be re- 
ferred several haemorrhages and dropsies produced by simple 
transudation in a tissue mechanically congested ; and although 
these effusions have really nothing active in their nature, yet 
are they considerably diminished, and sometimes altogether 
removed, by blood-letting, which in such cases acts in a man- 
ner purely mechanical, by removing from the vessels the fluid 
by which their parietes were kept in a state of over-distention. 
These pathological observations are quite exemplified in the 
majority of those cases of haemoptysis, hasmatemesis, ascites 
and other effusions, which are connected with organic disease 
of the heart. 

An increase in the volume of the part affected with me- 
chanical hypereemia is a necessary consequence of the great 
quantity of blood with which its vessels are distended ; hence 
the mere circumstance of a membrane being thicker than nat- 
ural is not sufficient to establish the existence of inflammation. 
In like manner, a tissue mechanically congested may lose its 
natural consistence, and become more or less friable ; whence 
we are led to conclude that neither the softening of a tissue, 
nor its increased thickness, can be admitted as unequivocal 
marks of inflammation. This remark is particularly applica- 
ble to the lungs, which always offer a less degree of resist- 
ance to the finger in those points where they are gorged with 
blood (generally their posterior part) than where their texture 



LESIONS OF CIRCULATION. 



43 



retains its natural appearance. The mode in which the lung 
when congested becomes more friable, may be easily explain- 
ed. When this viscus, as in its natural state, contains much 
air and little blood, the air, an elastic fluid, being easily com- 
pressible, readily escapes from under the finger, and with it, 
the portion of solid tissue which invests it ; but when in place 
of an elastic compressible fluid, the pulmonary parenchyma 
contains only an incompressible liquid, such as the blood, it 
can no longer glide from under the finger, and being pressed 
between two forces, it yields, and is broken down. 

It now remains to consider whether we can, by any well- 
defined anatomical characters, distinguish in the dead body the 
mechanical hyperemia from the two other species which have 
been previously considered. From what has been said in the 
preceding part of this article, it will at once be seen, that such 
a distinction is oftentimes impossible ; the arborescent appear- 
ance of the vessels, and the uniform red colour being common 
to all the species of hyperemia. On the other hand, the injec- 
tion of the larger venous trunks belongs more exclusively to 
mechanical hyperemia. But in order to distinguish this species 
from the others, we must in general attend less to the appear- 
ance of the part congested, than to other circumstances ; such 
as the kind of death which the individual has died, the nature 
of the preceding disease, and the state in which the other 
organs of the body are found. Thus, it will be advisable to 
examine whether the large veins which bring back the blood 
from the part congested are filled with blood or empty ; whether 
the cellular tissue in different parts of the body, and especially 
that which invests the arteries is injected ; whether the paren- 
chymatous, as well as membranous tissues which are most 
disposed to congestion, are gorged with blood ; and lastly, 
whether the right and left cavities of the heart, and the large 
blood-vessels which communicate with them are in a state of 
emptiness or otherwise. By uniting all these methods of in- 
vestigation, we shall in some cases be enabled to decide with 
certainty ; in other cases we shall attain only to a greater or 
less degree of probability ; whilst in others we must be con- 
tented to doubt. When treating of each organ in particular, 



44 LESIONS OF CIRCULATION. 

I shall detail more fully the peculiar appearances which may 
enable us to distinguish between the mechanical, the sthenic, 
and the asthenic, forms of hyperaemia. 



ARTICLE IV. 

Hyperemia formed after Death. 

We have already seen in the preceding article, how differ- 
ent parts of the body may present a red colour and congested 
appearance, in consequence of some mechanical obstacle to 
the venous circulation, occurring during die life of the individ- 
ual : it now remains for us to see, that after death, the same 
appearances and the same varieties of colour may be produced, 
by the influence of those physical and chemical laws, whose 
action, suspended, or modified by the powers of life, is quickly 
restored when the counteracting force of vitality ceases to 
oppose it. 

That sanguineous congestions are really formed after death 
on the surface of the body, may be proved to demonstration ; 
the several steps of their formation may be traced, and the 
causes which favour their production appreciated. On the 
bodies of almost all persons dying of acute diseases, and whose 
vascular system at the time of death was filled with blood, the 
skin which covers the most dependent parts, especially the 
back, and the calves of the legs, will be found to present an 
uniform livid red colour, disposed in stripes or patches. In 
other bodies is observed another kind of coloration, which is 
not confined to the dependent parts of the body, but appears 
on the arms, thighs, thorax, and abdomen, in the form of red 
streaks which sometimes run parallel, and sometimes intersect 
each other in different directions. If portions of skin thus 
coloured be dissected, the following appearances are pre- 
sented. 1. In the dependent parts, the dermoid tissue is filled 
with blood ; its adherent surface is lined with a net-work of 
veins ; the adipose tissue which fills its areolae is stained red ; 



LESIONS OP CIRCULATION. 45 

and in the subcutaneous cellular tissue small patches of ecchy- 
mosis are observed, and large veins are seen ramifying, disten- 
ded with a dark brown or black blood : this disposition of the 
subcutaneous vessels is most remarkable under the occipital 
portion of the scalp. 2. In those parts of the skin which, though 
not dependent, present a streaked red appearance, these 
streaks will be found to follow the course of the veins, and 
seem produced by a true sanguineous suffusion into the der- 
moid tissue, a suffusion which appears to result after death 
from the transudation of the blood through the parietes of its 
vessels. 

But if sanguineous congestions can be thus formed after 
death in the cutaneous surface, analogy would lead us to sup- 
pose, a fortiori, that similar congestions may be formed in 
those tissues which are situated in the interior ; for in the last 
moments of life the blood flies from the surface, and accumu- 
lates in the internal organs. In those organs therefore we 
should, a priori, expect that sanguineous congestions would be 
formed after death, not only when the mass of blood is consid- 
erable at the moment of dissolution, but even after protracted 
chronic affections, when even the small quantity of blood 
which remains in the system, is almost wholly accumulated in 
the capillaries of the internal organs. Observation confirms 
the justice of this reasoning ; for if the body of an animal be 
opened immediately after death, and the state of the organs 
as regards their colour and the disposition of the blood, be at 
the time carefully noted, and if those same organs be again 
examined at successive intervals, the blood will be found to 
accumulate gradually in different parts, which immediately 
after death contained no more than the rest; parts naturally 
white will turn red ; vessels will become visible where not a 
trace of vascularity could be previously observed ; there will 
be developed a coloration of a uniform red tint, disposed in 
isolated spots, long stripes, or broad patches ; the blood will 
be seen escaping from its vessels, and forming more or less 
extensive effusions around them, or else soaking through the 
neighbouring tissues and imparting its colour to them ; and, 
lastly, the colouring matter of the blood will be seen uniting, in 



46 LESIONS OF CIRCULATION. 

the different serous cavities, and in several points of the cellu- 
lar tissue, with the colourless albuminous fluid which had been 
previously effused, or else seen transuding through the tunics 
of the vessels with the serum, if this fluid had not been pre- 
viously effused separately. At last when the body, no longer 
endowed with life, begins to decompose under the influence 
of those laws which govern all inert matter, various gases are 
disengaged, which, traversing the coats of the minute vessels, 
impart an unusual colour to the blood, just as they are found 
to do in the case of the experiment where they act on this fluid 
through the coats of the bladder in which it is contained. In 
this manner are produced the different brown, livid, and 
greenish hues observable on bodies undergoing putrefaction. 
The concave surface of the liver is generally the first part to 
present this appearance, in consequence of its vicinity to the 
transverse arch of the colon, which usually contains a large 
quantity of those gases, and also in consequence of the vast 
proportion of blood contained after death in the capillaries of 
the liver, which is thus placed in the most favourable circum- 
stances to undergo these chemical alterations : it is not until 
after the liver and adjacent parts are thus coloured, that the 
abdominal muscles and subsequently the integuments present 
the same appearances. Theory might easily have led us to 
anticipate these results of observation. 

In summing up the causes which are capable of producing 
hypersemia after death, we are led to recognize several genera 
and species, which may be arranged as follows : 

First Genus. — Hyperasmia produced at the moment of 
death. — Cause : the contractility of tissue which resides in the 
small arteries continuing to act after the heart has ceased to 
beat. 

Second Genus. — Hyperaemia produced at a certain period 
after death : this genus comprehends the following species : 

First Species.— Hyperaemia by hypostasis, or dependent 
position. 

Second Species. — Hyperasmia by transudation of the blood, 
or of some of its component parts, through the parietes of its 
vessels. 



1ESI0NS OF CIRCULATION. 47 

Third Species. — Hyperemia by chemical affinities. 
I shall enter into some details respecting each of these genera 
and species. 

First Genus. 

Hyperemia produced at the Moment of Death. 

We generally date the moment of death from the time 
when the respiration and action of the heart cease to be per- 
formed. After that period, however, the contractility of the 
arteries still survives for a certain time, and, by virtue of this 
contractility, the arteries propel the blood they contain onwards 
towards the capillary system, in which it must consequently 
accumulate, as no force then exists whereby the capillaries may 
be enabled to propel their contents into the veins. Hence it 
arises, that the different capillary networks are uniformly found 
in a state of congestion in the bodies of those persons who die 
with much blood in their system. These congestions will of 
course vary considerably according to the quantity of blood, 
and also according to the manner in which the circulation was 
finally interrupted ; whether in both sides of the heart, in the 
large venous and arterial trunks, in the capillaries of the lungs, 
or in those of other parts of the body. There is often a strong 
analogy between certain asthenic hyperemias which are form- 
ed while the heart still continues to beat, and this cadaveric 
hyperemia formed at the moment when the visible phenomena 
of life cease to exist. 

Second Genus. 

Hyperemia produced at a certain Period after Death. 

In whatever position the body is placed after death, the 
blood quickly passes from the more elevated to the most de- 
pendent parts of the different organs. By taking advantage 
of this circumstance, we can at pleasure produce the red con- 
gested appearance of the lung in either its posterior, lateral, or 
anterior surface, by laying the body immediately after death on 
its back, side, or face ; we can in like manner give to different 



48 LESIONS OF CIRCULATION. 

coils of the intestines a red vascular appearance, by simply 
suffering them to hang in a more dependent position than the 
adjoining parts, and retaining them for some time in this 
position. The parts which most frequently present this hypos- 
tatic congestion are, on the exterior, (as we have already seen,) 
the skin of the occiput and of the back ; and, internally, that 
part of the membranes of the brain, which corresponds -to the 
occipital region, and its continuation which lines the posterior 
part of the spinal canal ; the lobes of the cerebellum, and the 
posterior part of those of the cerebrum ; the portion of the 
lungs situated posteriorly at each side of the spine in the con- 
cave surface of the ribs ; the most dependent portion of the 
stomach, (supposing the body to be lying on its back,) and 
those folds of the intestines which are likewise the most depen- 
dent, and towards which the blood must consequently gravitate 
from the neighbouring intestinal folds and from the mesentery. 
All these parts may present every shade of redness, from the 
slightest blush produced by the injection of a few minute ves- 
sels, to the uniform deep red colour which results from the 
most intense congestion. 

Besides the hyperoemia by hypostasis, there is yet another 
species formed after death, which results from the transuda- 
tion of the blood or some of its constituent parts through the 
coats of the vessels. 

So long as life continues, the fluids contained in the several 
cavities cannot escape through the membranous parietes of 
these cavities ; but this impermeability does not depend on 
their texture or organization, so much as on the vital forces by 
which they are animated ; for when these forces cease to ex- 
ist, the membranes become permeable to different substances 
which they contained during life. This fact is exemplified by 
the escape of different gases through the parietes of the colon, 
which announce their presence in several of the surrounding 
parts, by the colours which they produce on entering into 
combination with the blood of those parts. The bile also 
transudes through the gall bladder, and stains the adjacent tis- 
sues. Can the blood in like manner pass through the parietes 
of the arteries and veins ? The following experiment seems 



LESIONS OF CIRCULATION. 



49 



favourable to this supposition. Introduce some pmssiate of 
potash into a vein or artery in a dead body, and on the outside 
of the vessel deposit some sulphate of iron ; in a short time 
the external surface of the vessel will present a blue colour, 
thus proving the transudation of the salt of potash through the 
coats of the vessel. Why should not these tunics be equally 
permeable to the blood ? Indeed the recent experiments of 
M. Dutrochet have established, as a constant fact, the transu- 
dation of liquids through their membranous parietes. 

The cadaveric transudation of the blood through the coats 
of the vessels, produces three phenomena : 1. When the blood 
arrives at the external surface of the vessel, it soaks through 
the adjacent tissues, and dies them of its own colour, just as 
the bile tinges those parts which immediately surround the 
gall bladder. 2. The blood is effused into the surrounding 
cellular tissue in the form of red spots of different dimensions: 
these ecchymosed spots are frequently found on the internal 
surface of the scalp, and in the great cul-de-sac of the stomach, 
where they are distributed along the course of the blood ves- 
sels. 3. The blood thus transuded may form collections of a 
red fluid in the different serous membranes : indeed, in almost 
every body opened at about six-and-thirty hours after death, 
these reddish effusions are found in the cerebral and spinal 
arachnoid, as well as in the pleura, pericardium and peritoneum. 
It does not appear that the blood which thus transudes through 
the coats of its vessels, necessarily retains all its component 
parts ; for if so, it would coagulate in the cellular tissue, and 
in the serous cavities into which it is effused : the fact is, that 
the serum and colouring matter pass through the vessels, 
whilst the fibrine remains behind either fluid or coagulated. 

Various circumstances influence the transudation of the 
blood or of its elements, through the parietes of the blood- 
vessels ; of these some relate to the state of the blood itself, 
others to the state of the vascular parietes. There are cer- 
tain diseases in which the blood retains a remarkable fluidity 
after death, and seems as if its particles no longer possessed 
their natural force of aggregation : in such cases the blood 
must necessarily have a greater tendency to escape through 
Vol. I. 8 



50 LESIONS OP CIRCULATION. 

the coats of its vessels. On the other hand, great thickness of 
the coats of the vessels presents an obstacle to the escape of 
their contents; accordingly we seldom observe traces of tran- 
sudation in the neighbourhood of the large veins or arteries. 
This transudation becomes more abundant, as the coats of the 
vessels are further advanced in the state of putrefactive de- 
composition. But, as the rapidity of putrefaction is extremely 
variable, it follows that, in some cases, no trace of transuda- 
tion from this cause can be observed at the expiration of 
twenty-four hours, whilst in others it commences much soon- 
er. The rapidity with which this hypersemia by transudation 
is formed, will also be found to vary materially, as the body 
has been kept in a dry or moist place, or at a high or low tem- 
perature. For instance, traces of this transudation are almost 
uniformly found in the mucous membrane of the intestines and 
elsewhere, in those bodies which are examined in private 
houses, where they are generally kept at a much higher tem- 
perature than in the theatres attached to hospitals. It is evi- 
dent that these circumstances can only influence the extent 
and rapidity of the transudation, by accelerating the putrefac- 
tive process, and perhaps also by contributing to maintain the 
blood in a fluid state. 

Lastly, as the time elapsed since death increases, various 
chemical affinities come into action, and produce certain ap- 
pearances of hyperemia. Thus, if a portion of lung or intes- 
tine be exposed to the atmosphere, although at the time of its 
exposure it presents little or no appearance of vascularity, a 
short time will suffice to produce in it a bright scarlet appear- 
ance, evidently resulting from the oxygenation of its blood, 
which, being more highly coloured, appears more abundant. 
If, instead of atmospheric air, other gases be employed, such 
for instance as are generated in the body during the process of 
putrefaction, the parts exposed to their influence soon present 
another series of colours. Thus, the internal surface of the 
intestines exhibits a livid or greenish cast which may pervade 
all the intestinal coats ; the lung assumes a greenish or black 
colour, and, on incision, a brownish liquid flows out, which 



LESIONS OP CIRCULATION. 51 

in its sensible qualities resembles putrefied blood ; and its 
tissue becomes at the same time friable and easily broken 
down. 

This state of the organ has often been mistaken for gangre- 
nous inflammation, whilst in reality it is simply an effect of in- 
cipient putrefaction, which it is by no means rare to observe, 
during the great heats of summer, even at a short period after 
death. 

I shall merely allude at present (as on a future occasion I 
shall enter into more minute details on the subject) to the uni- 
form red tinge which the internal coats of arteries often pre- 
sent, and which, in many cases at least, is produced by the 
combination of the colouring part of the blood with the mem- 
rane which it bathes.* 

Such are the different forms of hyperacmia formed either 
during life, or after death, the- existence of which appears to 
me fully established by a strict and impartial observation of 
facts ; and, if it be true, as I have endeavoured to prove, that 
these several varieties cannot always be distinguished by well 
defined anatomical characters, it is evident that simple inspec- 
tion cannot in all cases enable us to decide as to the nature of 
the cause which may have produced those sanguineous conges- 
tions that are found on dissection. 

There is one phenomenon which is liable to succeed to all 
these species of hyperaemia, namely, the escape of the blood 
from its vessels, and its effusion, either on the free surface of 
the membranes, into the areolas of the cellular tissue, or into 
the parenchymatous texture of the different organs, where it 
causes by its deposition a certain disorganization. No doubt 
can now be entertained that haemorrhage may follow those 
hyperaemias which are produced by a mechanical cause. Sev- 
eral years have elapsed since Boerhaave saw haemorrhage 
from the intestines produced by the application of a ligature 
round the vena porta? of a living animal ; and it is highly proba- 



* See on this subject, in the 2d Vol. the chapter which treats of the diseases 
of the sanguiferous system. 



52 LESIONS OF CIRCULATION. 

ble that certain hasmoptyses which occur in individuals labour- 
ing under aneurism of the heart, proceed altogether from the 
mechanical obstacle which is thus presented to the pulmonary 
circulation. The blood likewise escapes from its vessels, in 
those hyperaemias which are formed after death, especially in 
those varieties which are caused by transudation and by hy- 
postasis. M. M. Rigot and Trousseau have frequently seen 
the blood exude from the intestinal surface of a coil of intestine 
which was suspended in a dependent position. In the article, 
which has been dedicated to the description of asthenic hy- 
peraemia, we have seen that haemorrhage may result from this 
species also, and that the haemorrhage in this case, as well as 
the hypercemia which produced it, is asthenic or passive. Last- 
ly, haemorrhage may almost be considered as one of the nat- 
ural terminations of active hyperaemia, so frequently are they 
combined. It is difficult to assign a reason, why two sthenic 
hyperaemias apparently similar in intensity and duration, shall 
nevertheless present this remarkable difference, that in one the 
blood shall escape from its vessels, whilst in the other there 
shall be no appearance of haemorrhage whatever. All that we 
know upon the subject may be summed up as follows : — 

I . There are some cases in which the ordinary signs of san- 
guineous congestion no sooner make their appearance, than 
the blood which flows to the organ affected escapes from its 
vessels, and haemorrhage ensues. The signs of congestion 
cease as the blood flows, and the general health is in no way 
deranged, provided the haemorrhage occurs in an organ of mi- 
nor importance, or that it be the result of a natural process, 
such as the menstrual discharge. If, however, the organ be 
one whose functions cannot be deranged with impunity, the 
general health will suffer a proportionate derangement, as in 
the case of apoplexy, or haemoptysis. In the latter disease, 
however, the health may be re-established, provided the whole 
quantity of the blood be only partially thrown up, or if it all 
remain effused into the pulmonary parenchyma, the derange- 
ment of the general health will be permanent ; as is exempli- 
fied in cases of extensive pulmonary apoplexy. When the 
bodies of persons dying during an attack of haemorrhage are 



LESIONS OF CIRCULATION. 53 

examined, the organs from which the blood was effused are 
sometimes found red and congested, whilst in other cases they 
are remarkably pale, and, with the exception of the blood ef- 
fused, present no morbid alteration whatever. Such for in- 
stance is the appearance often presented in cases of haemor- 
rhage from the brain, bronchia, stomach and intestines. This 
pale state of the bleeding tissues cannot be admitted as proof 
that no congestion had existed either before or during the 
haemorrhage ; all that it establishes is the simultaneousness of 
the afflux of blood to the tissue, and of its escape from its ves- 
sels. 

2. Blood may for some time continue to accumulate in the 
vessels of a tissue, without making its escape ; and in conse- 
quence of this accumulation, gives rise to various functional 
and organic derangements ; but the haemorrhage does not 
commence until a later period, when all the symptoms of in- 
flammation have been fully developed. In all such cases the 
quantity of blood effused is never so great as in the ordinary 
forms of haemorrhage, as will readily appear by instituting a 
comparison between pneumonia and haemoptysis, dysentery 
and melaena, &c. 

3. When an organ has been irritated, the blood which flows 
thither in consequence of that irritation, may at first escape 
from its vessels in large quantities, and subsequently cease to 
be effused ; and it is at this latter period when the haemorrhage 
ceases, that the most formidable symptoms generally occur. 
In such cases the hyperaemia has only changed its form, but 
still persists ; sometimes assuming an acute type, and advan- 
cing rapidly towards its termination, whether favourable or fa- 
tal ; sometimes, also, retaining a latent chronic character, and 
laying the foundation of various alterations of nutrition in the 
organ where it exists. Thus haemoptysis is sometimes trans- 
formed into pneumonia, haematemesis into gastritis, menor- 
rhagia into metritis, &c. ; thus also these haemorrhages, after 
recurring frequently, and leaving some trace of hyperaemia af- 
ter them at each visit, lay the foundation for the developement 
of tubercles, in the lungs, and of that degeneration termed 
cancer, in the stomach and uterus. 



54 LESIONS OF CIRCULATION. 

4. We have just seen that haemorrhage is in some cases the 
source from which various chronic alterations of nutrition de- 
rive their origin ; it is in others evidently the effect of some of 
these alterations of nutrition ; such for instance as induration, 
ulceration, accidental productions, &c. ; around which, con- 
gestions, possessing a peculiar tendency to terminate by haem- 
orrhage, are frequently formed. 

5. There are some active hyperemias, which, whether ex- 
isting simply, or combined with other organic derangements, 
have never been accompanied with the slightest extravasation 
of blood, either at their commencement, during their progress, 
or at their final termination. 

6. Morbid anatomy does not afford any distinctive charac- 
ters between the post mortem appearances, presented by those 
cases which were attended with haemorrhage, and those which 
were not. 

We know not what the peculiar modification is, which the 
texture of an organ undergoes, so that in one case it allows 
the blood determined towards it to escape from its vessels ; in 
another it forms pus, or exhales only a thin serum ; whilst in a 
third it becomes indurated, softened, or ulcerated : but there 
is one common link which unites these different alterations, 
and hence it is, that under the influence of apparently the same 
causes, we often see them produced indifferently, and not un- 
frequently replaced one by the other. Thus an attack of 
coryza may be ushered in by epistaxis, which may be succeed- 
ed, first by a total cessation of secretion from the affected 
membrane, next by a serous exhalation, and subsequently by 
a puriform exhalation, which in its turn may be succeeded by 
a return of the epistaxis, with which the disease first com- 
menced, and by which it terminates. But in all this series of 
phenomena we can perceive, throughout the whole course of 
the irritation, one constant lesion, namely, the hyperemia; 
and a succession of morbid alterations in the organic action of 
the tissue affected, producing alternately, haemorrhage, cessa- 
tion of all secretion, exhalation of serum, and of pus, and, last- 
ly, a recurrence of the haemorrhage. I might also adduce here 
the well known fact, that in many cases of inflammation of 



LESIONS OF CIRCULATION. 55 

serous membranes, which present no perceptible difference 
either in their nature, duration, or intensity, pure blood is some- 
times found effused, sometimes a simple albuminous fluid, and 
sometimes perhaps false membranes, &c. 

Thus from the observation of symptoms, as well as from the 
inspection of the part from which the blood flows, (which can 
be made in cases of cutaneous haemorrhage,) we arrive at this 
conclusion, that active haemorrhage is uniformly preceded by 
the sanguineous congestion of the organ or tissue affected. 
But are we hence authorized to conclude that every species of 
haemorrhage depends on increased vascular action ? In my 
opinion, certainly not ; for we can easily understand how cer- 
tain haemorrhages may depend exclusively on some modifica- 
tion of the organic disposition of the coats of the vessels, in 
consequence of which they may allow the blood to escape. 
Such a modification surely may exist without depending more 
on a sthenic, than an asthenic state of the vessels : indeed this 
fact appears to me abundantly proved by those cases of haem- 
orrhage which yield to the application of astringents, after 
blood-letting and other antiphlogistic measures have been re- 
peatedly employed in vain. 

. There are other cases again, in which the haemorrhage can- 
not properly be referred to either the sthenic or asthenic hy- 
peraemia, nor yet to any peculiar modification in the texture of 
the vascular parietes ; but is evidently dependant on some 
peculiar state of the blood itself. To this cause may be at- 
tributed the sanguineous effusions which occur in the follow- 
ing cases. 1. After profuse haemorrhages. I recollect a case, 
in which, after a violent attack of epistaxis, small extravasa- 
tions of blood appeared all over the cutaneous system, and 
subsequently disappeared as a fresh supply of blood was gen- 
erated in the system. 2. Towards the termination of chronic 
diseases which reduce the system to an extreme state of de- 
bility, and by which the blood is diminished in quantity, and 
in its quality altered to a thin serous fluid. 3. In other indi- 
viduals with whom this general debility and this watery state 
of blood are constitutional. 4. In scorbutic persons. In all 
these cases it seems as if the blood, deprived of its natural 



5G LESIONS OF CIRCULATION. 

degree of consistence, could more easily transude through the 
coats of its vessels. On a future occasion I shall revert to this 
subject, and shall then enter more minutely into particulars. 



CHAPTER II. 

Anaemia. 

This state is precisely the reverse of that which I have de- 
scribed under the name of hyperaemia. An organ affected 
with anaemia contains a less quantity of blood than should cir- 
culate through it in its natural healthy state. The anaemia is 
incomplete if the organ only receives a less quantity of blood 
than natural ; it is complete when the organ receives no blood 
at all : this latter case is much more rare than the preceding. 
Anaemia, like hyperaemia, may be either local or general. We 
shall first consider the local affection. 



ARTICLE I. 

Local Ancemia. 

The circumstances under which anaemia of an organ is most 
frequently observed, and which seem in a greater or less de- 
gree to favour its production, are the following : 

1. A diminution in the calibre of the artery which conveys 
the blood to the organ affected. However, in estimating the 
degree of importance which should be attached to this cause, 
we should recollect that it is by no means established, that the 
diminution in the size of the artery in all cases precedes the 
anaemia ; on the contrary, it seems just as reasonable to sup- 



LESIONS OF CIRCULATION. 57 

pose, that the capacity of the artery diminishes in consequence 
of the organ to which it is distributed having itself a tendency 
to atrophy, and consequently requiring a less supply of blood 
for its nutrition. 

2. Certain modifications of the nervous influence which so 
materially affects the greater number of organic phenomena. 
Thus, under the influence of a strong mental emotion, the 
blood suddenly flies from the cutaneous capillary vessels of 
the face, or of the whole surface of the body ; and what is 
well worthy of attention is, that the very same impression 
which in one individual causes the blood to recede from the 
surface, will, in another, cause it to rush with impetuosity into 
the superficial vessels : accordingly we have all observed that 
a deadly paleness or a crimson flush may indifferently succeed 
to an access of passion or a strong emotion of terror. 

These phenomena, trivial as they may appear, are never- 
theless deserving of our attention for the light which they 
throw on the interpretation of certain phenomena that occur 
in other and more important organs under the influence of the 
same causes. Why, for instance, may we not suppose that, 
under the influence of similar causes, the stomach may blush 
like the skin, or like it, turn pale ? In these cases the anaimia 
is only momentary ; but if the nervous cause which has once 
produced it be often repeated, this state of anasmia may be- 
come habitual, and thus produce, for instance, the pale com- 
plexions so frequently observed in men -whose minds are con- 
stantly engaged, who are tormented by violent and agitating 
passions, or who are of what is generally termed a nervous 
temperament, even though no organ be deranged in its struc- 
ture or fuction. 

3. The hyperemia of one organ sometimes produces the 
ansemia of another, or others. In a great number of cases, as 
we have seen in the first chapter, when a hypersemia has form- 
ed in any one point of the system, it has a constant tendency 
to extend itself to other parts ; there are, however, other cases 
in which at the same time that the blood flows towards one 
organ, and accumulates there, it abandons other parts, and 
leaves them in a condition comparatively exsangueous, which 

Vol. I. 9 



58 LESIONS OF CIRCULATION. 

may be either temporary or permanent. A sort of balance of 
hyperemia and anasmia (if I may use the expression) is thus 
established between the organs. On the surface of the body, 
the skin furnishes us with frequent examples of this ; and in 
the interior, dissection shews a similar state of parts : for ex- 
ample, the brain, in one case is congested, and in another re- 
markably exsangueous, at the same time that some other or- 
gan is affected with a greater or less degree of hypersemia. 
In many cases of acute peritonitis, the mucous membrane of 
the intestines is remarkbly pale. 

4. An antecedent state of hypersemia in the same organ 
which at present suffers from anaemia. 

5. There are some cases in which none of the circumstances 
here enumerated, nor indeed any other appreciable cause, 
can be discovered, and yet the post-mortem examination ex- 
hibits such an extraordinary state of anaemia in one or more 
organs, that not a single drop of blood can be discovered in 
their minute vessels, or even made to appear by pressure, in- 
cision or laceration. However, as the organs, even in this 
bloodless state, must have necessarily continued to receive 
some nutritive fluid, it is highly probable that the blood circu- 
lated in their capillary vessels, not indeed in its natural condi- 
tion, but deprived of its colouring matter ; thus assimilating 
these organs (as regards their circulation) to certain tissues 
which are naturally supplied with colourless blood, just in the 
same manner, I conceive, as all the organs are nourished in 
white-blooded animals. In the course of this treatise we shall 
have frequent occasion to remark, that the diseased state of an 
organ in the human body, is the physiological and healthy con- 
dition of the same organ in other animals. The parts in 
which I have particularly observed this extreme degree of 
anasmia are, the brain, heart, liver, stomach and other portions 
of the alimentary canal, and certain muscles of animal life. 

An organ affected with anaemia may present no other alter- 
ation than a change of colour, being pale and perfectly exsan- 
gueous ; this change may, however, be complicated with 
other morbid lesions. Thus, its volume may be diminished ; 
indeed it is evident that the activity of its nutrition must de- 



LESIONS OF CIRCULATION 59 

crease when it no longer receives its natural supply of blood. 
Its consistence may likewise undergo some modification ; we 
learn from observation that the bloodless state of a tissue or 
organ frequently coincides with its softening. At the same 
time that certain membranous tissues, such as the serous, mu- 
cous, and cutaneous, are in this exsangueous condition, the 
extraordinary activity of their secretions often presents a stri- 
king contrast to the small quantity of blood which they con- 
tinue to receive. These facts may serve to convince us that all 
alterations of secretion or nutrition do not necessarily infer the 
existence of sanguineous congestion in their respective organs. 

When the supply of blood to an organ is suddenly inter- 
rupted, as occurs when its artery is at once obliterated, (by 
compression, ligature, or other mechanical means, such as in 
M. Cruveilhier's experiments of injecting quicksilver, &c.,) if 
the circulation be not quickly re-established by some collateral 
branches, the organ, deprived of the blood which should support 
it, speedily becomes gangrenous, and dies. Here then we have 
an example of the same effect, gangrene, produced by three 
different and apparently opposite causes. I. By a mechanical 
obstacle to the arrival of blood (anaemia from the sudden ob- 
literation of an artery). 2. By an unusual afflux of blood (an 
advanced stage of active hyperemia). 3. By the stagnation 
of blood in the capillary vessels (various degrees of asthenic 
hyperemia). In all these cases however, though apparently 
so different, the cause which determines the gangrene is really 
the same ; namely, the absence of arterial blood, whether its 
arrival be obstructed by a ligature applied round the trunk 
of the artery, or by the stagnation of the blood already in the 
minute capillary vessels. 

Of the functional derangements which result from the anae- 
mia of an organ, some are peculiar to this affection, and may 
consequently enable us to recognise its existence during life ; 
whilst others, both local and general, are precisely similar to 
those produced by hyperemia of the same organ. Thus, con- 
vulsions, delirium, and a thousand other nervous symptoms, may 
be produced indifferently by the brain receiving either a great- 
er or a less supply of blood than natural ; and thus also the same 



60 LESIONS OF CIRCULATION. 

disorders of digestion may result from hyperemia of the stom- 
ach, or from the diametrically opposite condition of that viscus, 
anaemia. The obvious conclusion to be drawn from these 
facts, is, that symptoms may in many cases deceive us as to 
the true nature of a disease, and that the practioner, who, in 
his treatment of this class of affections, trusts exclusively to 
their guidance, must inevitably run the risk of committing the 
fatal error of combating anaemia by bloodletting, and of treat- 
ing sthenic hyperaemia by excitants, and and asthenic hyperae- 
mia by antiphlogistitics. 



ARTICLE II. 

General Ancemia. 

This expression, taken in its rigorous signification, is incor- 
rect ; for the system can never suffer the total and complete 
absence of blood, without the heart ceasing to act, and the 
other phenomena of life becoming extinct : the term hypcemia 
would therefore be more correct. The quantity of blood in 
circulation may, however, be so diminished as no longer to 
penetrate the minute vessels of the cutaneous surface, in which 
its place is supplied by a thin serous fluid : and after death, a 
deficiency, or even total absence, of blood is observed not only 
in the large arteries, veins, and right side of the heart, but 
likewise in the capillary system, which is remarkably pale and 
colourless. In these cases, the membranous and parenchy- 
matous tissues, such as the brain, lungs, liver, kidneys, alimen- 
tary canal, and the parenchyma of the heart and muscles, are 
also remarkably pale and exsangueous. 

This state of general anaemia may supervene without any 
appreciable cause. I have more than once had occasion to 
observe it in the bodies of persons who died dropsical, without 
presenting any alteration of the solids, such, at least as could 



LESIONS OF CIRCULATION. 61 

be discovered by our mode of investigation. (Clinique Med. 
T. iii. p. 558.) The use of food not sufficiently nutritive ; the 
habitual respiration of an impure, moist atmosphere, from 
which the sun's rays are excluded, and which is ill adapted to 
the due performance of the pulmonary and cutaneous func- 
tions ; any organic lesion which affects directly or indirectly 
the parts engaged in the process of haematosis ; are all so many 
circumstances, which both reason and experience point out as 
calculated to produce general anaemia to a greater or less ex- 
tent. Moreover, when an organ labours under chronic affec- 
tion, the vital powers become concentrated in that organ ; and 
although it may not have in any wise contributed to the pro- 
cess of haematosis, it nevertheless causes a considerable dim- 
inution in the quantity of the blood. 

In the same manner as the blood, when too rich y or too 
abundant, gives rise to a certain train of morbid phenomena 
which have been already noticed, so, when too poo?' in quality, 
or too scanty in quantity, it produces various functional disor- 
ders, on which sufficient attention has not, in my opinion, been 
bestowed by modern pathologists. 

When the system loses a large quantity of blood in a short 
space of time, the action of several organs is singularly de- 
ranged ; the functions of the nervous system are peculiarly 
affected, producing not only faintings, and the ordinary and 
natural symptoms of debility, but likewise other phenomena, 
which are generally supposed to depend on an over-excited 
state of the nervous system. Thus, in such cases there often 
supervene, delirium, convulsions, palpitations, and laborious 
respiration such as is observed in cases of pulmonary conges- 
tion. In this latter case, (pulmonary congestion,) the dyspnoea 
proceeds from the quantity of blood in the lungs being too 
great in proportion to air inspired for its aeration ; whereas in 
these cases of anaemia just alluded to, the dyspnoea proceeds 
from the reverse cause, namely from the circumstance of the 
air inspired bearing an excessive proportion to the blood which 
it has to aerate ; so that in this case of dyspnoea, the individual 
is placed much in the same circumstance as when an animal 
is confined under a glass jar filled with pure oxygen. The 



62 LESIONS OF CIRCULATION. 

function of digestion is also impaired ; as the due performance 
of this process requires that the stomach, when it has received 
the food, should become the seat of a certain degree of san- 
guineous congestion ; which in persons labouring under gen- 
eral anaemia is manifestly impossible. All these morbid phe- 
nomena subside as a fresh supply of blood is generated in the 
system. 

We sometimes see the same train of phenomena supervene 
in other circumstances, where there has not been, as in the 
preceding cases, a sudden abstraction of a large quantity of 
blood ; but where, under the influence of some of those causes 
I have enumerated, the mass of blood is considerably, though 
gradually, diminished, in consequence of its expenditure for 
the general purposes of the ceconomy not being duly compen- 
sated by a fresh supply. Thus, for example, we frequently 
observe the train of symptoms above enumerated, in persons 
who have been kept during a tedious convalescence on too low 
a regimen : in such cases the symptoms are precisely similar 
to those which are usually attendant on a protracted state of 
inflammation, but in this instance evidently depend on a very 
different cause, as they uniformly disappear when the diet is 
improved, and a fresh supply of blood thus generated. To 
these facts, I beg leave to add the analogous observation of 
Dr. Gaspard. This accurate observer relates {Journal de 
Physiologie Experimentale) that in a country devastated by 
famine, where grass was for a considerable time the only arti- 
cle of sustenance which the wretched inhabitants had to sub- 
sist on, several of them exhibited unequivocal symptoms of 
general anaemia, and became dropsical. 

I have already enumerated in the list of causes of general 
anaemia, the protracted deprivation of the genial influence of 
the solar rays, and the constant respiration, in a dark place, of 
an impure atmosphere, the constituent principles of which are 
ill adapted to the due aeration of the blood. Now, such pre- 
cisely were the circumstances under which several persons 
employed in a coal mine were every one gradually seized with 
a remarkable state of anaemia. The history of these cases ap- 
pears to me so interesting, and at the same time so illustrative 



LESIONS OF CIRCULATION. 63 

of the present subject, that I shall transcribe the following pas- 
sage from the " Dictionnaire de Medicine," article " Anemie." 

" All the workmen employed in one of the galleries of a coal 
mine in Auzain were taken ill in the summer of the year 11 ; 
which was at the time considered the more remarkable, as 
none of the miners had previously been affected, although this 
gallery had been constantly worked for several years before. 
The men who worked in the adjoining galleries were not af- 
fected, although the only difference which could be observed, 
was, that the latter were somewhat shorter, and rather better 
ventilated than the other. The disease was ushered in by vio- 
lent colic pains, accompanied with meteorismus, and black and 
green stools ; these symptoms were soon succeeded by dysp- 
noea, palpitations, and great prostration of strength ; which 
gradually disappeared at the end of ten or twelve days, when 
the symptoms of general anremia began to make their appear- 
ance. The countenance lost all colour and complexion, and 
presented an appearance similar to that of wax which had 
been tinged yellow by the influence of time ; the blood-vessels 
were so completely effaced that not a trace of them could be 
discovered even in those regions where they are generally most 
apparent ; not a single capillary vessel could be seen on the 
conjunctiva of the eye or eyelids, or even in the mucous mem- 
brane of the mouth ; and the pulsation of the arteries was so 
feeble, as to be scarcely perceptible. These various symptoms 
were constantly presented even during the febrile paroxysms 
which occasionally supervened. The patients all complained 
of excessive debility, great anxiety, frequent palpitations, and 
sense of oppression and suffocation on making the least exer- 
tion ; they had constantly profuse sweats ; their countenance 
was cedematous ; their appetite good, but digestion much im- 
paired ; and their emaciation advanced with rapid strides. 

" This state sometimes lasted for six months or a year, and 
in some cases terminated in death ; which was often preceded 
by the re-appearance of the original symptoms. The pro- 
tracted duration of this affection, as well as its refusal to yield 
to the ordinary modes of treatment, determined the medical 
gentlemen in attendance to consult the Society of the School 



64 LESIONS OF CIRCULATION. 

of Medicine in Paris, respecting the nature and treatment of 
the disease. Four of the patients were sent to Paris, and 
placed under the care of Professor Halle, in the hospital of the 
Faculty. The remedies first employed consisted of light, nu- 
tritious diet, combined with bitter infusions of hops and gen- 
tian ; to these were added, antiscorbutic wine, and mercurial 
frictions ; the last more as an experiment, than from any par- 
ticular indication. During this treatment one of the patients 
died : on dissection all the arteries and veins were found void 
of blood, and containing only a little serum ; no blood flowed 
when the muscles were divided, except on the thigh, from the 
large muscles of which a few drops issued. This almost total 
absence of blood, which agreed so well with the phenomena 
observed during life, induced M. Halle to discontinue the mer- 
curial frictions, and substitute the internal use of iron filings, in 
the dose of a drachm daily, combined with tonics and opium. 
In eight or ten days an evident improvement had taken place 
in the patients thus treated : a few veins began to appear un- 
der the skin of the fore-arm ; the digestion was much improv- 
ed ; and the dispncea considerably relieved. Each subsequent 
day the patients pointed out as a new discovery one or more 
blood-vessels which had just become visible ; all their symp- 
toms continued to improve, and at the time they were sent 
home their health was perfectly re-established. 

" Appearances similar to those above mentioned were ob- 
served in the same parts of the bodies of several who died of 
this affection ; and the same plan of treatment was employed 
with equal success at Dunkirk, where some of these patients 
had been sent, and at Auzain itself. During convalescence 
relapses were frequent."* 

In this unusual form of disease, the circumstances attendant 
on its developement, the symptoms which accompanied its 
progress, the morbid appearances observed on dissection, and 
finally the method of treatment found most successful, all con- 
spired to prove that some defect in the important process of 



* Dictionnaire de Medicine, Tom. ii. art. Anemie by Chomel. 



LESIONS OF CIRCULATION. 



65 



haematosis was the immediate and proximate cause of the dis- 
order, and of the whole train of morbid phenomena which ac- 
companied it. Another circumstance in this disease which 
merits attention is, that its commencement was ushered in by 
diarrhoea and other formidable symptoms, which after a few 
days disappeared, and were succeeded by a state of general 
anaemia, which every day became more marked. In this, as 
in many other cases where the cause of the disease acts prin- 
cipally on the blood and nervous system, the morbid phenom- 
ena which the different organs present seem evidently con- 
nected with the primary and predominant affection of these 
two grand vital agents. Again, as, in the cases at present un- 
der consideration, there were profuse perspirations without 
inflammation of the skin, and serous infiltration of the cellular 
membrane without inflammation of that tissue ; so likewise, I 
conceive, the diarrhoea was produced by an increased exhala- 
tion from the mucous membrane of the intestines, indepen- 
dently of any congestion, or irritation of that membrane. I 
might if necessary adduce several pathological facts to support 
this opinion from analogy ; such as the cases of many individ- 
uals who, when brought to the verge of the grave by long pro- 
tracted disease, and reduced to an almost perfect state of an- 
aemia, were seized with profuse serous diarrhoea a few days 
before death, and on dissection presented no more traces of 
disease in the mucous membrane of the intestines, than had 
been observed during life on their skin, which had been con- 
stantly bathed in sweat. 

In chlorosis, several of the morbid phenomena first record- 
ed are constantly observed ; and if this disease, as is now gen- 
erally admitted, frequently results from a defective formation 
of blood, the cause of which may reside exclusively in the ner- 
vous system, can we with any show of reason refer either to 
irritation or sanguineous congestion, the Proteus-like variety of 
functional derangements which chlorotic patients so constant- 
ly present ; such as epileptic paroxysms, convulsions, chorea, 
dyspnoea, palpitations, vomiting, &c. 1 Or shall we not ap- 
proach nearer the truth in assigning these different morbid 
phenomena to the same cause which produces them in per- 

Vol. I. 10 



66 LESIONS OF CIRCULATION. 

sons who are reduced to a state of anaemia by the deprivation 
of food, light or wholesome atmosphere ? We may appeal to 
the test of experience, to the lsedentia and juvantia, for the 
further confirmation of this doctrine. Venesections employed 
in such cases to combat an irritation which in reality does not 
exist, invariably produce a marked aggravation of all the symp- 
toms ; on the contrary, it frequently happens that by stimula- 
ting the nervous system of these chlorotic patients by the phys- 
ical and moral emotions of matrimony, we produce a more 
natural complexion and colour of the whole cutaneous surface, 
thus indicating a corresponding improvement in the process of 
sanguification ; and in proportion as the anaemia disappears 
under the influence of this new modification of the nervous 
system, the whole train of diseased action, the difficult respira- 
tion, constant sensation of uneasiness and listlessness, impaired 
digestion, gastralgia, vomiting, tympanitis, and limpid urine, 
together with all the strange nervous symptoms, which seemed 
dependent on some organic alterations of the solids, gradually 
subside and eventually vanish, as a fresh supply of blood is 
generated in the system. 

To conclude, when the duration of this state of general 
anaemia exceeds a certain limit, another series of disorders 
supervenes. The different organs, in consequence of receiv- 
ing a less supply of blood than natural, undergo various modi- 
fications of nutrition, whence result the atrophy, the diminu- 
tion of thickness and consistence of several tissues, perhaps 
also, the total disappearance of some of them, during the 
course of long protracted chronic diseases. In these cases, 
the organs fall into decay in consequence of their no longer 
receiving a due supply of blood ; just as in the foetus, those 
organs are either altogether deficient, or incompletely devel- 
oped, if a sufficient quantity of the nutritive fluid be not sup- 
plied to them ; and as in the adult, these organs may at pleas- 
ure be reduced to a state of atrophy, by mechanically dimin- 
ishing the afflux of the blood to them. 

Such are the principal phenomena which may be considered 
as the primary and immediate effects of the state of general 
anaemia ; but let us now suppose the supervention of an attack 



LESIONS OF CIRCULATION. 67 

of inflammation in an individual thus circumstanced. We 
have already seen that in such an individual the nutrition and 
vitality of all the organs are peculiarly modified ; that every 
organ in the body really enjoys a less degree of vitality than 
natural, inasmuch as it no longer receives a sufficient supply 
of that fluid, on which its existence depends. It is therefore 
evident, that such a state of the system cannot fail to influ- 
ence materially the character and termination of the inflam- 
mation, which, under such circumstances will produce the 
most alarming symptoms, and frequently too the most fatal con- 
sequences, the ceconomy being (if I may use the expression) 
defenceless. The various acts of innervation will be per- 
formed with extreme irregularity ; there will be a sudden 
prostration of strength, a constant tendency to haemorrhage, 
and a remarkable disposition to mortification wherever con- 
gestions are formed ; and since the vis vitse is actually dimin- 
ished throughout the whole system, the laws which govern all 
inorganic matter will commence to exert their influence over 
the body while yet alive, and produce the various symptoms 
of decomposition and putrescency. 

As in determining the true nature of this disease, so like- 
wise in our selection of remedies, the local affection must not 
engross our attention ; for in reality these symptoms do not 
depend on the intensity of this affection, so much as on the 
peculiar conditions of the ceconomy, both as regards its in- 
nervation and nutrition. The local inflammation is the occa- 
sional cause of these symptoms, but their real source is seated 
in the peculiar conditions of the ceconomy which preceded its 
appearance. 



68 LESIONS OF NUTRITION. 



SECTION II. 



LESIONS OF NUTRITION. 



The function of Nutrition is liable to various modifications': 
1, in the arrangement and distribution of the elementary mole- 
cules of which the several tissues are composed ; 2, in the 
number of these molecules ; 3, in their consistence ; and, 4, in 
their nature and properties. 

Deviations from their natural arrangement and distribution 
of the elementary particles of the tissues, produce the various 
species of congenital malformations usually called Monstros- 
ities. 

Alterations in their number give rise to hypertrophy or atro- 
phy, both which states may in turn become the causes of sev- 
eral malformations. 

Alterations in their consistence produce induration or soft- 
ening of their respective tissues. 

From a diminution in their number or consistence result 
various lesions, such as ulceration, perforation, &c. 

Lastly, alterations in their nature and properties of these 
molecules produce in the part affected, the transformation of 
one tissue into another. 



LESIONS OF NUTRITION. 69 



CHAPTER I. 

Lesions of Nutrition depending on the irregular Arrangement 
and Distribution of the anatomical Elements of which the 
Solids of the Body are in their natural State composed. 

To this class are to be referred the various congenital aber- 
rations of nutrition, which produce a conformation of one or 
more organs different from that which naturally belongs to 
the species or sex of the individual. The term monstrosity, 
which is now generally used to express these malformations, 
was for a long time employed to represent such anomalies of 
nutrition only, as were sufficiently great to produce extraor- 
dinary or hideous deformities in the external confirmation of 
the body ; but in the classification formed on these principles, 
several malformations were omitted which differed only in 
situation or degree ; no attempt was made to investigate their 
causes, or ascertain their conformity to any principle deduced 
from the laws of organization ; and, in consequence, the his- 
tory of monstrous formations was almost wholly composed of 
an incoherent assemblage of marvellous tales, inaccurate de- 
scriptions, superstitious ideas, and absurd prejudices. Even 
physicians themselves long viewed malformations in the same 
light. Accordingly we find that amongst the numerous ac- 
counts of monsters, published even as late as the commence- 
ment of the eighteenth century, there are few, if any, which 
are calculated to assist the investigations of the scientific in- 
quirer of the present day. It is not without surprise that, 
even after that period, we find in the memoirs of the Acade- 
mic des Sciences, a description, with plates, of those imaginary 
beings, mermen, like the tritons of ancient fable. Shortly af- 
ter the period alluded to, however, a new era commenced ; 
and according as the spirit of experimental philosophy was in- 
troduced into the cultivation of the sciences, was felt the ne- 
cessity of giving a new direction to inquiries of this nature, 
in order to render them really useful. Morgagni corrected 



70 LESIONS OF NUTRITION. 

several erroneous opinions respecting the nature and causes 
of monstrous formations. Haller collected all the facts re- 
lating to this subject which were recorded by his contempo- 
raries and predecessors, submitted them to a judicious analysis, 
and deduced from them several conclusions eminently calcu- 
lated to promote the advancement of the science. But it is 
to the indefatigable researches of modern anatomists that we 
are indebted for the greatest advances which have been' made 
in this department of medical science : an idea fraught with 
the most important results, and which was originally con- 
ceived by Littre in the year 1700, has been recently revived, 
developed, and extended by M. M. GeolFroy St. Hilaire, 
Serres, Beclard, Breschet, Chaussier and Adelon, Jourdan, 
and others, in France ; and by Soemmering, Frederick Meck- 
el, and Tiedemann, in Germany. This idea consists in regard- 
ing a certain number of monstrosities as the result of an arrest, 
or suspension of the progress of the developement of the or- 
gans of the foetus : and in those cases where no evidence ex- 
ists of any such suspension of developement having taken 
place, but where, notwithstanding, nature seems to have de- 
parted from her established rules, these aberrations have been 
reduced to certain determinate laws, by an acquaintance with 
which, all the different varieties of monstrous formations may 
be determined, foreseen, and, I might almost say, calculated. 

The principle of the unity of organic composition, so ably 
advocated by M. Geoffroy St. Hilaire, is not, according to this 
illustrious naturalist, in the least violated by these monstrous 
productions ; but, on the contrary, derives additional support 
from them. In the course of this chapter we shall have occa- 
sion to cite the facts he has adduced in support of his opinions, 
which, whether they be applicable only to some particular in- 
stances, or capable of comprehending all, are worthy of atten- 
tion. As Cuvier says, even though the supporters of this doc- 
trine may not have succeeded in establishing it, still the vast 
number of facts and ideas they have collected are not the less 
valuable on that account. 

It would be quite inconsistent with the plan and object of 
this Treatise to give a detailed description of each monstrosity 



LESIONS OF NUTRITION. 71 

that occurs. I shall therefore content myself with endeavour- 
ing to lay down the general principles, and point out the laws, 
which may serve to guide the scientific inquirer in the study 
of monstrous productions, and help him to recognize, classify, 
and denominate such malformations as may be submitted to 
his investigation. 

If we take a general view of the different abberations from 
the natural state to which organized bodies are liable, we shall 
find that they are all referable to two classes ; viz. vicious con- 
formations, and alterations of structure. The latter class sel- 
dom make their appearance until after birth ; whereas the 
former generally occur in the mother's womb, before the in- 
dividual is perfectly formed. When malformations occur at a 
later period, they are almost invariably produced by some al- 
teration of stricture of the part ; as, for instance, scales on the 
skin, horny excrescences, &c, which are denominated mon- 
strosities by the vulgar, but which in scientific language must 
be carefully distinguished from them, as the term monstrosity 
should be exclusively restricted to those transformations which 
are congenital. Even at this early stage of our investigations, 
some analogy may be traced between the human foetus and 
those animals which occupy a much lower rank in the scale of 
organization ; for, in the lower classes of animals, such as 
zoophytes, the conformation of their organs is not so absolute- 
ly determined by fixed laws, but that it may be modified and 
changed under the influence of certain causes which influence 
their nutrition. But, in those animals, this condition obtains at 
all periods of their existence, whereas in man, it is almost ex- 
clusively confined to the period of his foetal life. 

We are not, however, to conclude that, because monstrous 
formations are observed at the period of birth, these malfor- 
mations must have been original ; or in other words, that be- 
cause an infant is deformed at its birth, it may not at some 
antecedent period of its foetal state, have enjoyed a natural 
conformation. We can in fact easily conceive how the pro- 
cess of conformation may have proceeded regularly during the 
earlier periods of the evolution of the foetus, and have been 



72 LESIONS OF NUTRITION. 

subsequently modified by some derangement or defect in its 
developement. 

The developement of the fetus may be modified in various 
ways : sometimes the formative process, or nisus formativus, 
as it has been termed, possesses less energy than natural, and 
the developement of the organs is in consequence suspended ; 
in which case they are found either imperfectly formed, or al- 
together deficient : sometimes, on the other hand, this force 
seems to acquire an excess of energy, and then, there is a cor- 
responding excess of developement, and the organs exceed 
their natural limits, either in size, or number. ' In other cases 
again, the developement cannot be properly said to be either 
excessive or defective ; but the formative process appears to 
have been simply perverted, thus producing various modifica- 
tions in the direction, and situation of the organs. We have 
examples of this in the general transposition of the viscera, and 
in certain varieties in the origin of the principal arteries. 

These facts are important in a pathological point of view ; 
for, if many malformations which cannot be accounted for by 
the simple excess or deficiency of the formative powers, can 
only be explained by admitting a derangement or perversion 
of those powers, we are, I conceive, authorized by analogy to 
admit in explanation of various alterations of texture, not only 
an excess or deficiency in the act of nutrition, but likewise a 
simple perversion of that act. 

To the three classes already enumerated, every species of 
monstrous formation may, I conceive, be referred. Meckel 
supposes, that these species form series rising by regular grada- 
tions from the natural form to the most unnatural deformity ; 
and that the intermediate gradations are not constituted by 
single or individual cases, but that every variety of monstrous 
formation is accurately repeated in other individuals ; so that, 
in fact, a separate and independent kingdom of monsters might 
be established. It must, however, be admitted, that the indi- 
viduals of this organic kingdom are not subject to such immu- 
table laws of developement, but that they may occasionally 
differ in some points from those monsters which come nearest 
to them in appearance : I must add, too, that M. St. Hilaire is 



LESIONS OF NUTRITION. 



73 



rather disposed to consider each individual monster as con- 
stituting in itself a distinct species. 

Whatever be the nature and number of these malformations, 
the implicit obedience to certain laws which nature constant- 
ly observes in the midst of these apparent anomalies, is very 
remarkable. Thus, the situation of the organs has never been 
so perverted, that the lungs were placed in the skull, or the 
brain in the pelvis ; nor have the organs been observed so con- 
founded together, as that the alimentary canal, for instance, 
made a continuous tube with the aorta, &c; all which would 
no doubt occur, if certain laws did not still preside over this 
state of apparent disorder and confusion. Another illustration 
of the existence of these laws is, that man and the higher or- 
ders of animals may present such an arrest in their develope- 
ment, that several of their organs shall represent exactly the 
natural state of these parts in the inferior animals ; whereas 
the latter can never attain such a degree of developement, as 
that their organs shall resemble the corresponding parts of the 
higher orders. Thus, for example, the human brain, arrested 
in its evolution, may present an appearance more or less ex- 
actly analogous to the brain of fishes, or reptiles ; but the sim- 
ple brain of these animals can never attain the degree of com- 
plicated structure which the human brain presents. Several 
malformations may exist together in the same individual ; in- 
deed such is perhaps the most frequent case, whenever the 
deformity is at all considerable. Sometimes these various 
malformations are all of the same class ; or in other words, 
are all produced by the same cause, for instance, by an excess 
or a deficiency of developement. Such vices of conformation 
constitute the compound monstrosities of Meckel; while his class 
of complex monstrosities comprehends all those which result 
from the existence in the same individual of malformations be- 
longing to different classes. 

The complex monsters, in Meckel's acceptation of the term, 
are the most common. Several of them result from the law 
so ingeniously conceived by M. St. Hilaire, which establishes 
that the exuberance of nutrition in one organ involves to a 
greater or less extent the total or partial atrophy of some other 

Vol. I. 11 



74 LESIONS OF NUTRITION. 

organ ; and vice verm. Innumerable applications may be 
made of this law of compensation, as it is termed, to the study 
of monstrosities. Thus, in several individuals who have on 
one hand, or foot, supernumerary fingers or toes, the hand or 
foot of the opposite side has fewer than ordinary. 

In a fetus with umbilical hernia, the left foot had only one 
toe, but the right foot had eight, and the eighth was divided. 
(Neumann.) In another fetus which had but one foot, the 
left hand had two thumbs. (Sue.) M. Segalas presented to 
the Academy of Medicine a fetus which had no thumb on the 
left hand, but had two on the right ; this same fetus had like- 
wise only eleven ribs on one side, but had thirteen on the 
other. Supernumerary fingers are often found in those cases 
where parts of greater or less importance are incompletely 
formed, or altogether deficient. In the case of Cyclopia, for 
instance, Meckel states that the number of fingers is very fre- 
quently augmented : a similar augmentation of these parts has 
likewise been observed to accompany hare lip, spina bifida, 
imperforate anus, absence of the genital organs, &c. In a 
case cited by Rosenmuller, in which the nasal bones were 
deficient, the ascending processes of the superior maxillary 
bones were so largely developed, that they met and supplied 
the place of the nasal bones. When several of the bones of 
the cranium are wanting, or exist only in a rudimentary state, 
those at the base of the skull sometimes acquire an extraor- 
dinary thickness, and a consistence like ivory. Again, when 
the brain is partially or totally deficient, the face often acquires 
an unusual developement, and by the extension of its bones in 
length or breadth, assumes a degree of resemblance to the 
face of certain animals. In those monsters called sirens, 
which have the lower extremities united, or partly deficient, 
the number of vertebrae and ribs is, according to Meckel, 
almost always preternaturally great. Elben remarks, in his ex- 
cellent work on acephalous monsters, that they frequently want 
the heart and liver, while at the same time their kidneys acquire 
an extraordinary degree of developement. Lastly, the applica- 
tion of this law of compensation may be observed also in those 
monsters which have several parts double : thus, monsters 



LESIONS OF NUTRITION. 



75 



with two bodies are often acephalous, while bicephalous mon- 
sters have been observed with spina bifida. In these two 
species of monsters, several organs present a very remarkable 
arrest of developement ; the abdominal parietes are deficient; 
the intestinal tube incomplete ; the urethra imperforate ; the 
rectum and bladder open into a common cloaca. The vascu- 
lar system, likewise, is excessively developed in some parts, 
and in others is so deficient as to be quite rudimentary : the 
heart especially is in many of these cases very imperfectly 
developed. ■ 

The supernumerary parts which result from an exuberance 
of nutrition, are likewise subject to this arrest of developement 
either in their entire structure, or in the different anatomical 
elements which enter into their composition. Thus supernu- 
merary limbs are in some cases mere shapeless stumps ; in 
others, though well formed externally, they are found on dis- 
section to be deficient either in their bones, muscles, or ten- 
dons, &c. 

Another application which Meckel has made of this law of 
compensation is, that in children born of the same parents, the 
monstrosity from excessive developement in one child, is often 
compensated by a corresponding deficiency in another. A 
young girl mentioned by Morand, had six fingers on each hand, 
and six toes on each foot, in all four supernumerary fingers 
and toes ; her sister had on each foot the regular number of 
toes, and on one hand the usual number of fingers, but on the 
other only the thumb, so that she wanted four fingers, exactly 
the same number that her sister had in excess. 

Monstrous formations proceeding either from excess or de- 
ficiency of developement do not occur with equal frequency 
in all organs. It may be laid down as a general principle, that 
those parts which are situated in the interior very seldom have 
their number augmented ; whereas the external parts are par- 
ticularly liable to this deviation from the natural state. The 
accuracy of this remark may be readily. ascertained by com- 
paring the extreme rarity of those cases, in which the heart, 
lungs, alimentary canal, or the genital or urinary organs have. 



76 LESIONS OF NUTRITION. 

been found redundant, with the comparative frequency of su- 
pernumerary limbs. 

If, however, setting the preceding considerations aside, we 
compare the different organs with regard to their respective 
liability to malformations, we shall find, that those which de- 
rive their nerves from the cerebro-spinal system, are in general 
the least subject to faults of conformation ; such, for example, 
are the muscular system, the larynx, and the lungs. On the 
contrary, irregularity of form is much more frequent in those 
parts which are principally supplied by the great sympathetic 
nerve ; such as the digestive, urinary, genital, and especially the 
vascular systems. This law, established by Meckel, is the 
more remarkable, as the cerebro-spinal system itself much 
more frequently presents irregularities of conformation, than 
do the ganglions of the great sympathetic. 

There are certain unnatural formations which occur indif- 
ferently at either side of the body ; as for instance, a deficiency 
or an excess in the number of fingers. Others again, have a 
peculiar predilection for the left side : Meckel has remarked, 
that when the cerebral artery arises immediately from the 
aorta, it invariably does so at that side. Another remark of 
Meckel's is, that those monstrosities that result from an exu- 
berance of nutrition, are more common in the superior than 
in the inferior parts of the body. Thus bicephalous monsters 
with a single body, are more common than monocephalous 
monsters with a double body. The fingers too are more fre- 
quently augmented in number than the toes, which, according 
to Meckel, corresponds with the earlier developement of the 
superior extremities. 

Female monsters are more common than those of the male 
sex. Out of forty-two monsters with double heads or double 
bodies, whose histories were collected by Haller, there were 
thirty females, nine males, two hermaphrodites, and one whose 
sex could not be determined. In eighty monsters examined 
by Meckel, there were sixty females, and only twenty males. 
The excessive proportion of female monsters seems to depend 
on the circumstance, that during the earlier period of the evo- 



LESIONS OF NUTRITION. 



77 



lution of the foetus, as in the lowest classes of the animal king- 
dom, there is only one sex, namely, the female ; so that in fact, 
when we say that the greater number of monsters are of the 
female sex, we only state in other terms, that in the greater 
proportion of monstrous formations, be their seat and nature 
what they may, the genital organs are arrested at an early 
period of their developement. 

The hereditary nature of certain malformations seems estab- 
lished by some very curious facts. We have the histories 
of whole families, every individual of whom had six fingers 
on each hand. Meckel records a remarkable instance of a 
man who had six fingers on each hand, and as many toes on 
each foot ; his eldest son alone presented a similar malforma- 
tion, and of four children belonging to the latter, only three 
presented the same anomaly as their father. Morand speaks 
of a woman who had twelve fingers and as many toes. She 
had a daughter whose toes only were above the natural num- 
ber ; this daughter had eight children, four of whom had six 
toes on each foot. Osiander relates the case of a woman, who 
was delivered of a monster with a double body, exactly sim- 
ilar to one to which her grandmother had given birth. Would 
not these facts almost justify us in supposing, that some of 
those strange and apparently useless conformations which cer- 
tain animals present, may have originally been monstrous for- 
mations, which were subsequently transmitted hereditarily, 
and are now so far from being considered unnatural, that they 
serve to characterise certain species, or varieties. 

Parents have been known to produce several children, every 
one of whom presented the same kind of malformation. Others 
again, after having had several weakly children, have produced 
others in whom there was an arrest in the developement of one 
or more organs. There are also cases on record, of the birth of 
twins having been followed by the birth of monsters with two 
heads, or two bodies. 

Having premised these general observations, I shall next 
endeavour to establish those laws which are more especially 
applicable to each of the three grand classes of monsters 
already mentioned ; and shall commence with that class which 



78 LESIONS OF NUTRITION. 

seems to proceed principally, if not solely, from an imperfec- 
tion of developement. 

This kind of monstrous formation does not occur with equal 
frequency in all the different organs. It may be laid down as 
a general law, that those organs. are most subject to imperfect 
developement, which are the latest in attaining their complete 
evolution ; and that every imperfection of developement an 
organ presents, corresponds exactly with the state bf that 
organ in some of the stages of its develope'ment. *I shall 
adduce some cases to illustrate this proposition. 

The intestinal canal is one of the first organs of which any 
trace is perceptible : at first it is only a continuation of the 
vesicula umbilicalis, which gradually elongates itself into two 
tubes ; one inferior, constituting the large intestine ; the other 
superior, forming the small intestine and stomach. Now in all 
the monsters hitherto examined, this primitive portion of the 
intestinal tube has been found perfect ; while on the other 
hand, those parts which are subsequently developed, have 
repeatedly been found deficient. Thus, in some cases, the 
prolongation of the vesicula umbilicalis does not extend down- 
wards, whence results the complete absence of the large intes- 
tine : or it may so happen that after its developement in this 
direction has commenced, its progress is arrested before its 
evolution is completed, in which case a part only of the large 
intestine will be found, such as a small portion of the colon, or if 
the colon is perfect, the rectum may be imperfect or altogether 
wanting. Sometimes it is the superior portion of the tube 
which is imperfectly or not at all developed, in which case the 
small intestine may consist only of the short tube, terminating 
not far from its origin, in a cul-de-sac ; or, if its developement 
be less incomplete, the intestinal portion may be perfect, but 
the stomach either totally deficient, or else so imperfectly 
evolved as to resemble the small intestine, of which it seems 
only a simple continuation. It is not as yet precisely ascer- 
tained how that portion "of the alimentary canal above the 
diaphragm is formed. Some authors are of opinion that it is 
evolved independently of the lower portion. There is a spe- 
cies of malformation which seems to favour this opinion, where 
the mouth and pharynx are well formed, but this latter organ 



LESIONS OF NUTRITION. 79 

terminates in a cul-de-sac, the oesophagus is altogether want- 
ing, and the stomach has no cardiac orifice. In these cases, it 
appears that the formation of that portion of the alimentary 
canal which "is above the diaphragm, proceeds from the mouth 
towards the stomach. • 

Whether we consider the bladder as a continuation of the 
allantoid . membrane or not, certain it is that this viscus is 
always" found at a very early period in the embryo, as 
also are the .kidneys. Hence we may conclude, a priori, in 
conformity with the law we have laid down, that the urinary 
apparatus may occasionally present different imperfections of 
developement, but can rarely if ever be completely deficient. 
The accuracy of this conclusion is confirmed by observation ; 
for some traces at least of this apparatus have been found even 
in those cases, when almost every other organ was either badly 
formed, or absent altogether. One case however is recorded 
by Fleishman, in which no trace of the urinary apparatus was 
discovered, although the intestinal tube and the liver were in 
their natural condition. These exceptions should not be lost 
sight of, especially in such a subject as the present, where 
some of the laws have been founded on the observation of only 
a few facts, and are consequently far from being certain. 

The nervous and vascular systems are likewise very early 
developed, their first lineaments being already perceptible in 
the midst of the homogeneous mass of which the embryo is 
composed at the earliest period of its existence. Notwith- 
standing, these systems present unnatural formations not less 
remarkable for their number, than for their variety. This 
exception to the general law is, however, more apparent, than 
real ; for although the rudiments of the vascular and nervous 
systems make thefr appearance at an early period of the evo- 
lution of the foetus, it is only at a very late period indeed, that 
their developement is complete ; if it can properly be consider- 
ed as complete even at the full period of gestation. Hence, the 
frequent occurrence of malformations in these two systems, so 
far from invalidating the law, serves, in fact, to confirm it. 
Each of these systems may in reality be considered as formed 
by the successive combination of several secondary systems, 



80 LESIONS OF NUTRITION. 

which have each an independent developement : now, if we 
examine the developement of the sesecondary systems, we shall 
find that such of them as are the earliest formed, are likewise 
those which are the least liable to irregularities of conforma- 
tion. If we take the nervous system, for example, we shall 
find that the nerves which, instead of growing from the brain 
or spinal cord, (as was for a long time erroneously supposed,) 
are developed before those parts, are likewise less frequently 
irregular in their conformation than they are. The spinal 
marrow too is formed before the brain, and, accordingly, is less 
liable to malformations ; and lastly, of the numerous parts 
which compose the brain itself, such as are the latest found, 
are also those which most frequently present irregularities 
in their developement. The term anencephalia, which is com- 
monly used as a generic term, to signify the different imper- 
fections of developement of the brain, is most frequently incor- 
rect ; for it very rarely happens, that the brain is (as this term 
would imply) altogether deficient ; the expression ateloence- 
plialia might therefore, perhaps, be substituted for it with 
advantage, as the term atelomyelia has already been employed 
by Beclard to designate the various imperfections of develope- 
ment in the spinal marrow. 

The remarks which have been made respecting the nervous 
system are equally applicable to the vascular. The heart is 
not the part of this system which is first developed, as was 
long imagined ; for certain vessels exist before any trace of 
the heart is perceptible. Its structure too, during the earlier 
periods of its evolution, is very different from the appearance 
it presents when fully developed : it is orginally a simple canal, 
which gradually dilates, and consists at first only of a single 
cavity, which is subsequently subdivided, according to certain 
laws which it would be foreign to my present purpose to enu- 
merate. Now, we observe, that certain parts of the heart are 
more subject to irregular conformation than others, and that 
such are uniformly the latest in attaining their complete devel- 
opement. For example, immediately before birth the foramen 
ovale is still open, and, accordingly, an open foramen ovale is 
of all malformations of the heart the most common. At a still 



LESIONS OF NUTRITION. 



81 



earlier period of foetal life, the septum of the ventricles does 
not exist, and we find that the absence or imperfection of this 
septum after birth is of much less frequent occurrence, than a 
previous foramen ovale. If we advance still nearer towards 
the period of conception, we find a period at which there is no 
fine of demarcation between the auricles and ventricles ; a 
similar conformation has been found in the full grown foetus, 
but not so frequently as in either of the malformations already 
mentioned. More rarely still has a simple vessel been found 
in the place of the heart ; and it will be recollected that this is 
the form which the heart presents at the earliest period of its] 
developement. Lastly, even this vessel has not been observed 
in certain acephalous monsters, which, with respect to the 
developement of their vascular system, remained stationary at 
that period when the whole circulatory apparatus of the em- 
bryo consisted in a single vessel proceeding from the amnion. 

The osseous system is one of the latest in attaining its com- 
plete evolution, inasmuch as it is not perfectly formed for a 
considerable time after birth ; it is likewise one of those which 
most frequently present defects of conformation. Of the dif- 
ferent parts of this system, those which are the earliest devel- 
oped are least subject to these defects ; amongst these is the 
clavicle ; on the contrary, those parts which are the latest de- 
veloped are most subject to them, as for instance the bones of 
the skull. In the course of this chapter I shall have occasion 
to recur to their malformations. 

In like manner, if we direct our attention to the external 
surface of the body, and the principal regions of which it is 
composed, we shall find that those parts which are most fre- 
quently absent or imperfect, are precisely the same as are la- 
test in attaining their natural developement. For example, at 
the first period of its formation, the fetus may almost be said 
to consist entirely of an abdomen ; accordingly, this part, more 
or less completely formed, has never been altogether deficient 
in any monster : on the contrary, there are several cases on 
record, in which no trace could be discovered of either head, 
neck, thorax, or extremities ; so that in fact nothing was to be 
seen but an abdomen, just as at the commencement of embry- 

Vol. I. 12 



82 LESIONS OF NUTRITION. 

otic life. The external parts of generation do not appear un- 
til very late ; and it is by no means uncommon, in the foetus^ 
arrived at its full term, to find these parts altogether deficient, 
or presenting some imperfection which constitutes their natu- 
ral condition at an early period of their formation. The mon- 
strous formations of the organs of sense are likewise subject to 
the same law. The eye which makes its appearance in the 
form of a black point, before any vestige of the external ear is 
perceptible, is not so often deficient as the ear. The eyelids, 
likewise, which are not developed until long after the ball of 
the eye, are more frequently absent or imperfect than the eye 
itself. 

Some authors have advanced an opinion that an organ can- 
not be imperfectly developed, or entirely deficient, unless 
when those organs which are formed before it in the natural 
order of developement, have likewise suffered an arrest in 
their evolution. This principle is certainly exemplified in 
some cases ; thus, an abdomen may exist without either head 
or thorax, whereas no monster has ever been seen consisting 
only of a head and neck. It has likewise been proved by ob- 
servation that, whenever the heart is deficient, the liver, which 
in its developement is later than the heart, is also deficient. 
But in other cases this principle of the dependance of the de- 
velopement of one. organ on that of another, is not borne out; 
the osseous system, for instance, frequently presents various 
anomalies, at the same time that the organs whose develope- 
ment is earliest, are perfectly well formed. 

The progress which has recently been made in the cultiva- 
tion of embryology and comparative anatomy, has taught us, 
that the greater number of the organs are much more inde- 
pendent of each other in their respective formation, than was 
for a long time supposed ; and that, consequently, any arrest 
in the developement of one organ, but seldom necessarily pro- 
duces a similar arrest in the developement of others. For in- 
stance, we now know that the nerves may be perfectly devel- 
oped, independently of the existence of the brain or spinal 
cord ; as has been abundantly proved in several cases of an- 
encephalia and amyelia. It appears that the nerves are pri- 



LESIONS OF NUTRITION. 83 

marily formed in those organs, which it is their office to con- 
nect with the centres of the nervous system ; and that they 
do not unite with those centres for a considerable time after 
their first rudiments are perceptible. Where these organs are 
deficient, the nerves are likewise deficient; so that the existence 
of the nerves depends much more on the developement of the 
organ which they are destined to supply, than on that of the 
nervous centres. M. Serres has recorded a remarkable illus- 
tration of this fact, in the case of a monster with two brains, 
and a single body, in which there were only two pneumogas- 
tric nerves found, arising one from the external side of each 
brain. In this case there were only two pneumogastric 
nerves, because there was only a single pulmonary and diges- 
tive apparatus for them to supply. In other cases, on the 
contrary, which M. Serres has cited, where these organs were 
double, and the brain single, there were two sets of nerves 
destined for the two sets of organs. 

These facts go a great way towards proving, that, not only 
the nerves, but likewise all the different organs, may attain 
their developement notwithstanding the deficiency of the ner- 
vous centres ; but, on the other hand, there are also facts 
which would lead us to infer, that, under certain circum- 
stances, there is at least an intimate relation between the per- 
fect developement of some organs and the complete evolution 
of the nervous centres : thus, when the cervical enlargement 
of the spinal cord does not exist, the upper extremities are 
(according to Serres) constantly deficient ; if it be the lumbar 
enlargement which is absent, the same author states that the 
lower extremities are as invariably wanting. In cases of con- 
genital atrophy, of the limbs, several authors, especially M. 
Rostan, have seen the hemisphere of the brain at the side op- 
posite to the deformity, converted into a serous sac, as if it 
had been early arrested in its developement, or, having been 
originally well formed, was at a later period attacked with 
dropsy. Be that as it may, these facts seem to announce a 
decided influence exercised by the nervous centres over the 
developement and nutrition of certain organs. 



84 LESIONS OF NUTRITION. 

There is another system, the absence or imperfect devel- 
opement of which has been regarded as the most powerful 
cause of all those unnatural formations proceeding from defi- 
cient developement ; I allude to the arterial system. Accor- 
ding to M. Serres, the absence or incomplete evolution of any 
part of the body depends on the defective developement of the 
artery which should supply the part with the materials for its 
nutrition and growth. 

The skilful anatomist is of opinion, that the evolution of 
each part of the nervous system is entirely regulated by the 
developement of its arteries, and that those parts of the brain, 
of which the arteries are earliest formed, are the first to attain 
their natural developement. Thus, we observe in the embryo, 
that the arteries which are distributed to the tubercula quadri- 
gemina, are largely developed at a period when the arteries of 
the brain and cerebellum are scarcely perceptible ; and for 
this reason, says M. Serres, the tubercula are formed before 
the hemispheres of the cerebrum or cerebellum. At a later 
period, the thalamus opticus, corpus striatum, fornix, and cor- 
pus callosum, gradually attain their natural form and dimen- 
sions, as their respective arteries increase in size. The same 
remark is applicable to the cerebellum ; as the early develope- 
ment of its middle lobe corresponds with the equally early de- 
velopement of its anterior artery, whilst its lateral lobes con- 
tinue in a rudimentary state until the period arrives for the 
developement of its posterior artery. In like manner, the de- 
velopement of the caudal extremity is, in animals, proportional 
to the size of the middle sacral artery, and in man is altogether 
deficient, as only a rudiment of this artery exists. The volume 
of the different organs is directly proportional to the volume of 
their arteries ; the great developement of the human skull in 
proportion to the face is thus accounted for : but when it so 
happens that the internal carotid artery is but imperfectly de- 
veloped, at the same time that the external carotid attains an 
unusual volume, the skull continues very small, and the face 
acquires an extraordinary size. Finally, the direction in which 
the evolution of certain parts proceeds, is likewise connected 
with the mode of developement of their arteries ; thus the 



LESIONS OF NUTRITION. 85 

hemispheres of the brain are formed from before backwards, 
like the carotid artery which supplies them ; on the contrary, 
the cerebellum is developed from behind forwards, as is also 
the vertebral artery by which it is supplied. 

These facts being established, M. Serres at once deduces 
from them the explanation of all the unnatural formations which 
proceed from defective developement ; thus, he supposes that 
in acephalous monsters the absence of the head depends on 
the absence of the ascending aorta, &c. 

This opinion, in which M. GeofFroy St, Hilaire also concurs, 
(and which he has so ingeniously advocated in his description 
of a monster termed by him podencephalus,) has not been gen- 
erally adopted by anatomists. It is admitted on all hands, that 
the volume of the different organs and of the respective arte- 
ries are directly proportional one to the other ; that, when an 
organ is accidentally increased in volume, its arteries experi- 
ence a corresponding increase ; and that, if from any accident 
it falls into a state of atrophy, the vessels which supply it with 
blood undergo a similar alteration. But, as was well remark- 
ed by Beclard, (in his lectures on monsters, delivered in 1822.) 
it is extremely difficult to decide, in this connexion of phenom- 
ena, which is the cause, and which the effect ; for there is no 
proof whatever in support of the opinion, that the develope- 
ment of the organs depends on the developement of the ar- 
teries, which is not equally applicable to the supposition, that 
the size of the arteries depends on the volume of the organs ; 
and that when the arteries are wanting altogether, it is because 
the organs which they should supply, are not evolved. Indeed 
this latter supposition derives considerable support from the 
fact, that in several cases the vessels are formed in the midst 
of their respective organs, where they first appear as isolated 
red points, which subsequently elongate themselves into canals, 
and then, and not before, communicate with the general vas- 
cular system. This mode of formation is particularly evident 
in those false membranes which are undergoing the process of 
organization, and which eventually become as perfect in their 
structure, properties, and functions, as the natural serous or 
mucous membranes themselves. Now in this case it is evident, 



86 LESIONS OF NUTRITION. 

that the artery could not have presided over the developement 
of the accidental tissue, but must have been produced in it, in 
the same manner as the other anatomical elements of which 
its texture was composed. Why should not the same phenom- 
ena take place in the formation of the different parts of the 
embryo, the primary developement of which has been with so 
much ingenuity and justice compared to the organization of 
false membranes? In further confirmation of this doctrine, we 
may remark, that some cases are authentically recorded, in 
which the brain was deficient, although the internal carotid 
gave off the regular cerebral branches, which were merely 
smaller than usual, and were distributed on the meninges. A 
very interesting case of this description, in which there existed 
no trace of brain except a portion of the crura, has been re- 
cently communicated to the academy by M. Baron. It ap- 
pears from the arguments which have been adduced on both 
sides of this question, that although a manifest connexion sub- 
sists between the developement of the arteries and that of the 
parts to which they are respectively distributed, the first of 
these phenomena cannot in strict reasoning be admitted as the 
cause of the second, either in the regular or irregular forma- 
tion. 

Another case in which an arrest of the developement of one 
part has been regarded as producing, more or less necessarily, 
a similar arrest in other parts, is when the parietes of certain 
cavities are imperfectly formed. It has been stated that, in 
such malformations, the organs contained in these cavities are 
likewise imperfectly developed. This rule holds good in many 
cases, but not in all. Fleishman, for example, has cited a case 
in which the pelvis contained no other organ than the rectum, 
and was reduced to much less than its natural dimensions ; but 
cases are likewise recorded, in which the genital and urinary 
organs were both deficient, and the pelvis was, notwithstand- 
ing, found of the natural size and form. In those cases where 
the diaphragm is wanting, and some of the abdominal viscera 
are contained in the thorax, the lungs are constantly found in 
a rudimentary state, their further evolution being impeded by 
the pressure exerted on them by the intruding viscera. 



LESIONS OF NUTRITION. 87 

M. Geoffroy St. Hilaire has most ingeniously availed him- 
self of this observation, to prove the existence of a pulmonary 
apparatus in the Crustacea, which he argues exists only in a 
rudimentary state in this family, on account of the peculiar 
form and dimensions of the cavity in which it is contained : in 
one genus of the Crustacea, however, the lungs become more 
apparent, in consequence of a partition which exists between 
the thorax and abdomen, and prevents the viscera of the latter 
cavity from protruding into the former, thus allowing a greater 
facility for the evolution of the pulmonic viscera. 

But of all the regions, the skull and spine are those in which 
a direct connexion can most constantly be established between 
the developement of the parietes and of their contents ; even 
in these, however, there are some exceptions to be pointed 
out. Thus M. Olivier has very justly remarked, that the im- 
perfections of developement of the vertebra? do not necessari- 
ly depend on those of the medulla spinalis, and vice versa. 
Cases of very extensive spina bifida have been observed, in 
which the spinal cord was perfectly well formed, and, again, 
the spinal cord has frequently been found imperfectly develop- 
ed, while the parietes of the vertebral canal were exempt from 
any irregularity. In the same manner, the skull may be nat- 
urally formed, although its contents exist only in their rudi- 
mentary condition, as is exemplified in certain cases of con- 
genital hydrocephalus. M. St. Hilaire adduces a case of a 
pig that presented peculiar monstrosity termed cyclopia, (both 
eyes united into one,) in which the brain did not fill above one 
third of the cavity of the cranium. He adds, that this is the 
only instance he is acquainted with, of a well formed cranium 
not being exactly moulded on the brain. Notwithstanding 
these exceptions, we should consider the following principle, 
established by M. St. Hilaire, as the general expression of a 
great number of particular facts : " The bones which envelope 
the brain, undergo in their developement various alterations 
which correspond exactly with those which the brain itself has 
undergone ; the greater the deficiency of the cerebral mass, 
the greater also will be the deficiency of the bones of the cra- 
nium, but still their rudiments are in general perceptible." This 



88 LESIONS OF NUTRITION. 

naturalist has established several species of anencephalous and 
acephalous monsters, according to the different arrangement 
and disposition of these rudiments. 

In three of these species the brain is altogether wanting. 
They have been named as follow : 1. The coccijcephalus 
(head having the form of the os coccygis) : in this species, the 
bones of the skull and neck are reduced to a state of ex- 
treme smallness, and surmount the vertebral column so as to 
resemble a sort of beak or os coccygis. Beclard has seen a 
case of this species, which he has described and figured in his 
memoir on acephalous monsters. 2. The cryptocephalus (head 
invisible exteriorly) : in this species, the head is, to use the ex- 
pression of M. St. Hilaire, reduced to a parcel of osseous 
masses, supported by a straight cervical column ; it is exces- 
sively small, and does not appear externally. (Beclard, op. cit. 
plate 4.) 3. The anencephalus (head without brains) : in this 
species, the skull is more apparent than in either of the pre- 
ceding, but is nevertheless singularly deformed : it is open 
down the median line, and each of the lateral parietes is re- 
flected outwards, en ailes de pigeon. 

In two other species, likewise established by M. St. Hilaire, 
the brain exists in a state of imperfect developement, and the 
evolution of the bones of the skull is much less imperfect 
These species are : 1. The cystencejrfudus (head with a ves- 
icular brain) : the skull is open as in the anencephalous species, 
but the lateral parietes are more approximated, and not everted. 
2. The derencephalus (head with the brain in the neck) : the 
skull is open posteriorly, as are likewise the cervical vertibrae ; 
and the brain, which is very small, rests on the occipital bones 
and on the vertebra?. 

With these species, in which there is at the same time im- 
perfect developement of the brain and of its osseous case, M- 
St. Hilaire groups others, which differ from them materially in 
this respect, that the brain is well formed and of its natural 
dimensions, but presents remarkable anomalies of situation in 
consequence of the malformation of its parietes. These cases 
in which the brain undergoes no modification except in its 
situation, furnish us with abundant evidence that an arrest of 



LESIONS OF NUTRITION. 89 

developement in the bones of the cranium, such as exists in 
these cases, does not necessarily produce a proportional arrest 
of developement in the brain ; so that even amongst the ex- 
amples adduced by M. St. Hilaire himself, we find exceptions 
to the law which he has laid down. 

There are several malformations, differing widely from each 
other, and apparently presenting the greatest discrepancies in 
their specific characters, which may nevertheless be traced to 
one common source, imperfect developement. Amongst these 
malformations may be enumerated the different accidental 
openings and separations of parts which, in the natural state, 
are united and closed. These solutions of continuity are all 
situated in the median line, and proceed from an arrest of 
developement. There is, in fact, a period in the evolution of 
the foetus, when almost every organ is composed of two parts, 
separated by an interval which subsequently diminishes and 
fills up, as the foetus approaches the full term of gestation. 
This gradual obliteration of the intervening space, proceeds 
from the fulfilment of a law demonstrated by M. Serres ; 
namely, that all the parts of the body are formed from the 
circumference towards the centre, and not, as was erroneously 
supposed, from the ceatre towards the circumference. Hence 
it follows, that if the evolution of an organ be arrested at any 
time near the period of its first formation, the organ so arrest- 
ed will in general be found composed of two parts, separated 
from each other by a certain interval. To this cause must be 
referred those cases which present a greater or less extent of 
deficiency in the parietes of the cranium, the spinal canal, the 
thorax, or the abdomen. The parietes of the cranium are 
most commonly deficient at the sutures ; those of the spinal 
canal present various degrees of separation, from the simple 
division of a spinous process, to a perfect cleft in the very 
body of the vertebra. The opening in the thoracic parietes 
consists sometimes of a simple cleft in the middle of the 
sternum ; in other cases this bone is altogether wanting, and 
in others, again, the ribs themselves exist only as rudiments, 
and appear like small appendices attached to the vertebrae. 
As to the abdominal parietes, their deficiency may consist in 
Vol. I. 13 



90 LESIONS OF NUTRITION. 

the absence of the Iinea alba ; or else the abdominal muscles 
themselves may be totally wanting, in which case the abdomen 
presents a large opening in front. There are some cases in 
which the abdominal parietes are deficient only in a small 
space above the pubis ; in these the anterior portion of the 
bladder is frequently deficient at the same time, and a moist 
reddish surface, from which a fluid oozes by a double orifice, 
is exposed to view between the umbilicus and pubis; this 
surface is the mucous coat of the posterior portion of the 
bladder. 

The bones of the pubis may, in like manner, continue in the 
same state of separation, as they naturally present at a certain 
period of fcetal life ; or may even be absent altogether: along 
with this, there may be observed posteriorly a complete or in- 
complete division of the sacrum and os coccygis. In all these 
unnatural formations, the same laws are observed as preside 
over the natural developement of the bones. Thus, in con- 
formity with the law of the formation of the organs from the 
periphery towards the centre, the ilium appears before the 
ischium, and the ischium before the pubis ; now, as the pubis 
is the last formed of these bones, so it also is the one which is 
most frequently wanting ; nor does its absence infer that of 
either of the other bones, whereas if the ischium be deficient, 
it is necessarily so likewise. 

The double or single division of the upper lip, and the fiss- 
ure of the roof and velum of the palate, producing the various 
degrees of harelip, represent the natural state of those parts at 
the commencement of fcetal life, and are therefore evidently 
caused by an arrest of developement. The lips, when first 
formed, are seemingly composed of as many distinct portions, 
as there are bones in the corresponding parts of the osseous 
parietes of the mouth ; and each of the intervals which separate 
these portions corresponds with the space interposed between 
the several bones, or, at least, between the several points of os- 
sification. The lower lip must, consequently, never be com- 
posed of more than two pieces, whereas the upper lip must at 
first be composed of four ; namely, two small portions in the 
middle, corresponding to the two ossa incisiva, and two lateral 



LESIONS OF NUTRITION. 91 

portions of longer size, which correspond each to a maxillary 
bone. It appears, that the two middle portions are very early 
united, as are also the ossa incisiva ; and hence arises the ex- 
treme rareness of a harelip situated on the median line, al- 
though the possibility of such a deformity, may, from what has 
been just stated, be easily conceived. On the contrary, the 
two lateral portions of the lip do not unite with the middle 
portion until a much later period : as this union does not take 
place at one, or at both sides, the malformation termed harelip 
will be either single, or double. The extreme rareness of the 
congenital division of the lower lip is satisfactorily accounted 
for, by the earliness of the period at which the two portions 
that originally compose it are united. 

Not only may the lips be arrested in the progress of their 
developement, and remain divided, as in the different varieties 
of harelip, but their evolution may even be suppressed alto- 
gether ; in which case the whole interior of the cavity of the 
mouth is exposed to view. 

Congenital hypospadias is also evidently an arrest in the 
developement of the male organs of generation, which are 
divided down the median line at a certain period of their for- 
mation. Traces of this original division may remain in the 
form of a channel or groove, running along the inferior surface 
of the penis ; the greater or less extent of this division con- 
stitutes the different degrees of hypospadias. In the first 
degree, a simple opening is observed underneath the glans ; in 
the second, this opening is continued along under the penis ; 
and in the third degree, the scrotum is itself divided, and the 
division of the urethra extends nearly to the bladder. These 
different degrees of hypospadias, especially the last, often co- 
exist with other malformations of the genital organs ; which 
may give rise to an appearance of hermaphrodism. For in- 
stance, at the same time that the urethra is open inferiorly, 
the penis, being small and imperforate, may easily be mistaken 
for a clitoris ; the division of the urethra may resemble the 
aperture of the vulva, especially when the scrotum is divided ; 
while each division of the scrotum, whether it contains a tes- 
ticle or not, represents with tolerable accuracy an external 



92 LESIONS OF NUTRITION. 

labium ; and in some cases, the division of the penis forms 
two folds, which descend to the perineum, and may be mis- 
taken for the nymphge. In all these cases, the resemblance to 
the female organs is much more striking when the testicles re- 
main in the abdomen. It is a very remarkable circumstance, 
that in a great proportion of those cases in which the original 
division of the male organs of generation continues to a 
greater or less extent, we likewise find other characteristics of 
the female sex, in these organs, as well as in the constitution 
and temperament of the individual. So constantly, indeed, is 
this the case, that it may be set down as a law, that, whenever 
the distinctive character of either sex is modified, the effect -of 
that modification is to produce a marked tendency to the 
character of the other sex. Thus, in extreme cases of hypos- 
padias, not only is the penis (as I have already remarked) 
diminutive and imperforate, but the testicles likewise are small, 
and instead of descending into the scrotum, remain in the ab- 
domen, at no great distance from the situation which, in the 
female, is occupied by the ovaries. The individual is feeble, 
and of the lymphatic temperament ; the voice is feminine, 
the beard scanty, and the breasts are sometimes remarkably 
developed. In like manner, in the female, when the clitoris 
attain an unusual size, the general appearance is masculine, 
and the chin is covered with hairs, &c. 

If we next turn our attention to the accidental apertures 
and communications, which many of the internal organs occa- 
sionally present, we shall find that they also are referable to 
an arrest in the developement of these organs. I have already 
alluded to the successive formation of the cavities of the heart, 
and may now remark, that all the unnatural communications 
between these cavities, which have been observed after birth, 
are the natural state of the parts at certain periods of the evo- 
lution of the foetus. In the female, the genital, urinary, and 
digestive organs, have often been found communicating, and 
uniting into a sort of common reservoir previously to their 
opening externally ; and if we follow these organs through the 
different stages of their developement, we shall arrive at a 
period when this triple communication was the natural con- 



LESIONS OF NUTRITION. 93 

formation of the parts. To the same class of malformations, 
should likewise be referred those cases in which certain ves- 
sels and ducts continue pervious after birth, which, in the 
natural state, should have had their cavities obliterated at that 
period ; such as the ductus arteriosus, the umbilical vein, and 
the urachus. 

A great number of congenital misplacements depend on the 
imperfect union of the parietes of the different cavities. In this 
way may be explained those cases, in which all the organs 
usually contained within the thorax and abdomen, are found 
on the outside of these cavities. To this cause is also to be 
attributed the unnatural situation of the brain, termed encepha- 
locele ; in which, however, while the skull continues open 
posteriorly, the several bones which compose its sides and 
base, sometimes change their natural situation : and, according 
to the position which they assume, the brain is protruded more 
or less completely out of the cavity which was destined to 
contain it : hence arise several forms of encephalocele, which 
have been particularly noticed by M. St. Hilaire. In one of 
these forms, the brain, thrust almost entirely out of the skull, 
is pushed downwards and backwards, and rests on the back, 
with no other covering than the common integuments. He 
has given to this species, on account of its situation, the name 
of notencephalus (head with the brain on the back). In other 
cases, it happens, that in consequence of the extraordinary 
elevation of the sphenoid bone, and the consequent alteration 
in the situation of the other bones, the brain is placed outside 
the skull, and seems supported on a pedicle which traverses 
the summit of the cranium. In these cases, the brain is im- 
perfect, many of its parts being deficient, (as the commis- 
sures,) or imperfectly formed, (as the tubercula quadrigemina, 
and the cerebral lobes,) whence arises its unusual form. They 
constitute the podencephalus (head with the brain on a pedun- 
cle) of M. St. Hilaire. This form is nearly allied to another 
species of encephalocele, described by this illustrious natural- 
ist, from whose works we have quoted so largely, under the 
name of hyperencephalus (brain situated on the skull). 



94 LESIONS OF NUTRITION. 

Other misplacements are likewise evidently the result of an 
arrest of developement : thus, the presence of the testicles in 
the abdomen, the situation of the kidneys in front of the ver- 
tebrae, the distance of the fundus of the gall bladder from the 
anterior margin of the liver, the immediate attachment of the 
hands to the scapulas, or of the feet to the ossa coxarum, are, 
in the adult so many misplacements, but were the natural 
situation of these parts at a certain period of foetal life. We 
must not, however, suppose that all Congenital misplacements 
may be thus accounted for. I once, for instance, found one 
of the kidneys in the pelvis ; and, as it received its artery from 
the hypogastric, its situation must have been congenital ; but 
I do not believe that such is the natural position of the kidney 
at any period of foetal life. 

As there are some malformations which consist of unnatural 
apertures and communications, so likewise there are others 
which result from the obliteration, or (more correctly speak- 
ing) the absence, of the natural openings and cavities. This 
species of monstrous formation, which has received the generic 
appellation of atresia, should, in like manner, be attributed to 
an arrest of developement. To this class belong imperforate 
anus, imperforate urethra, the termination of different portions 
of the intestines in a cul-de-sac, the non-obliteration of the 
membrana pupillaris, the absence of the frontal and maxillary 
sinuses, &c. When the testicles remain in the abdomen, the 
inguinal canal is often obliterated ; but, in this instance, the 
atresia is adventitious, not original. The hemispheres of the 
brain have, in some monsters, been found without any lateral 
ventricles : this deficiency is evidently the result of an arrest 
of developement in the hemispheres; for, it is an established 
law, both in comparative anatomy, and in embryology, that 
cavities do not exist in any part of the brain, until that part 
has attained its maximum of developement. As the cerebral 
hemispheres are in man at their maximum of developement, 
so, according to the law just laid down, they should contain 
cavities in their interior ; but, if we trace the evolution of the 
foetus to its commencement, we shall find, that the hemispheres 
are, at a very early period, much less developed than other 



LESIONS OF NUTRITION. 95 

parts, than the tubercula quadrigemina for instance. Accord- 
ingly, the tubercula contain a much larger cavity, at that pe- 
riod, than the hemispheres do ; at a later period this propor- 
tion is reversed. If, however, we suppose a stop put to the 
developement of the brain, the parts will remain in their prim- 
itive state ; the hemispheres will be found without ventricles, 
and a cavity will be observed in the tubercula quadrigemina. 
Such was the state of these parts observed in the monster de- 
scribed by M. St. Hilaire, under the name of podencephalus, 
to which I have already alluded. 

After atresia, follows, naturally enough, the class of malfor- 
mations termed by M. Breschet, symphysid, which consists in 
the unnatural union of parts that are usually divided ; whether 
by simple approximation, or by double organs running into one. 
This class comprises several malformations of peculiar interest, 
which may, like the preceding, be satisfactorily accounted for 
by an arrest of developement. The species of symphysia that 
has longest attracted attention, is that which consists in the 
union, or more or less perfect incorporation, of the eyes, which 
thus become situated in the median line : it has been described 
under the different names of cyclopia, monopsia, and rhinence- 
phalia. 

Cyclopia, which is a defect more common in certain animals 
than in man, constantly co-exists with the absence or imperfect 
developement of the olfactory bulbs and nerves, and of the eth- 
moid bone ; so that, in this case, it is evidently the absence of 
one organ of sense, which produces the displacement of the 
other. Indeed, we might expect a priori, that the absence of 
the osseous parts usually interposed between the orbits, would 
be followed by the mutual approximation and confusion of the 
latter ; but, in this confusion of the orbits, and, consequently, 
of the organs which they contain, there exist several degrees, 
which I shall now proceed to describe. 

We may consider as the first degree, that in which both 
orbits communicate, in consequence of the imperfect develope- 
ment of their internal walls ; but the eye in each still continues 
separate and distinct. In the second degree of this malforma- 
tion, there is only a single orbital cavity, containing the two 



90 LESIONS OF NUTRITION. 

eyes, which are in contact, but are not confounded together. 
In the third, both eyes are united, and run into one ; while the 
compound eye thus formed, still contains all the parts belong, 
ing to each ; the humours and membranes being all double, as 
is also, in general, the optic nerve. In some cases, however, 
there is only one optic nerve, although there are two crystal- 
lines. In several of these monstrous formations, a superficial 
observer would suppose there was only one eye ; but, on ex- 
amining its structure, all the constituent parts of the two eyes 
will most commonly be found, enclosed in one sclerotic as a 
common envelope. Sometimes, however, the eye is really 
single ; in which case it is always remarkable for its extraordi- 
nary size. — (Haller.) Lastly, Tenon, and before him, Bartholin, 
have recorded cases in which there was a total deficiency both 
of eye and orbit : this constitutes the" anopsia of authors. In 
some cases of cyclopia mentioned by Haller, it is stated that a 
single eye was furnished with two lachrymal glands and four 
eyelids. 

In cyclopia, the nasal bones abandon their natural situation, 
and are placed in the middle of the forehead, where they form 
a considerable prominence, from which the soft parts descend 
like a proboscis, or snout ; hence, the denomination rhinencepha- 
lus, which M. St. Hilaire has given to this species of monster. 
In several of these cases we likewise find a singular conforma- 
tion of brain, namely, a single lobe, ill developed, and situated 
in the median line ; to which circumstance, perhaps, as much 
as to the absence of the olfactory apparatus, is the cyclopic 
malformation to be attributed. 

We have just seen that the junction of both eyes co-exists 
with the absence of the organ of smell ; and if, in addition to 
this deficiency, the different parts of the buccal cavity are also 
wanting, (astomla,) other sensorial organs will likewise evince 
a disposition to meet, and unite in the median line. In this 
manner is produced another species of symphysis, which con- 
sists in the approximation and sometimes the union of both 
ears. In a case of this kind, described by M. St. Hilaire under 
the name oftriemcephalus, from the simultaneous absence of the 
organs of taste, sight, and smell, the ears were united inferiorly, 



LESIONS OF NUTRITION. 97 

and at the central point of their junction was situated a single 
external aperture leading to a single tympanum ; while there 
was a prolongation of skin, somewhat similar in form to the 
external ear, situated at each side. In other cases more or 
less analogous to the preceding, both the tympana are firmly 
united in the median line. M. St. Hilaire states that this dis- 
position may present a striking resemblance to the lower jaw, 
which in these cases often exists only in a rudimentary state. 

There are certain organs which, in consequence of imperfect 
developement, have their dimensions increased considerably 
beyond the natural standard : of this class are, the liver, thy- 
mus gland, supra-renal capsules, and clitoris. The spinal 
marrow, also is occasionally found longer than natural ; appa- 
rently because the vertebral canal is not sufficiently developed. 
There is a certain period in the evolution of the embryo, when 
the os coccygis is much longer than it is afterwards, and con- 
stitutes a sort of tail. Now, if this bone does not diminish in 
proportion as the lower extremites increase in size, as, accord- 
ing to the natural order of formation, it should do ; the conse- 
quence will be, that the foetus is born with a caudal prolonga- 
tion, which, in reality, depends on an imperfection of develope- 
ment. 

It seems equally paradoxical to assert, that an augmentation 
in the number of certain parts is the result of an arrest of devel- 
opement in these parts ; yet such is the fact with respect to the 
osseous system. Sometimes this numerical augmentation is 
real ; as when the ossa wormiana fill up the spaces left between 
the bones of the cranium in consequence of their imperfect 
development. The most remarkable of these ossa triquetra, 
or wormiana, as they are indifferently called, is that which has 
been named epactal (os intercalatum) : it is formed after birth, 
and is situated between the occipital and parietal bones, when 
they have ceased growing before the interval which exists be- 
tween them during the period of foetal life has been obliterated. 
Most commonly, however, this appearance of supernumerary 
bones in the full grown foetus is more apparent than real ; and 
depends on the circumstance of the different pieces which each 
bone was originally composed, continuing distinct, as they nat- 
Vol. I. 14 



98 LESIONS Or NUTRITION. 

urally exist at different periods of the evolution of the embryo, 
as well as in certain animals. Thus, for example, all anato- 
mists agree in describing the os frontis as originally composed 
of two distinct pieces, which subsequently become united along . 
the median line ; but no anatomist, as far as I am acquainted, 
has noticed the fact, that each of these lateral pieces was itself, 
in the embryo, composed of two other subdivisions, the one 
appertaining to the cranium, the other to the orbit. I have, 
however, satisfactorily ascertained the separate existence of 
these two portions, in certain foetuses, whose developement was 
arrested in its progress. In one of these, which was an anen- 
cephalous monster, the orbital portion alone existed ; its termi- 
nation was marked by a sharp edge in the situation where the 
superciliary ridge is usually found. In another fetus affected 
with hare lip, and in which the central portions of the parietes 
of the cranium, thorax, and abdomen, were deficient, I found, 
the cranial and orbital portions of each lateral division of the 
os frontis perfectly distinct and separate from each other ; so 
that each side of the frontal bone was actually composed of 
two portions separated from each other by an oblique line 
extending from below upwards, and from within outwards, and 
reaching from the internal angle of the orbit, to the outer mar- 
gin of the os frontis. This retardation of the union of the 
osseous portions has become, in the hands of several modern 
anatomists, a powerful argument in favour of the theory of the 
unity of organic composition. 

There are, however, also certain cases in which the bones, 
especially those of the skull, instead of appearing larger or 
more numerous than natural, seem, on the contrary, almost 
totally deficient. Now, as I have just endeavoured to estab- 
lish that the augmentation in the number of these bones is in 
general only apparent, so also M. St. Hilaire has attempted to 
prove, that, in the majority of cases, their absence is in like 
manner more apparent than real. According to this anatomist, 
the skulls of anencephalous monsters present all the individual 
bones appertaining to these parts in their natural state, subject, 
it is true, to infinite varieties in their form and size, but uni- 
formly consisting of the same materials, and presenting the 



LESIONS OF NUTRITION. 99 

same connexions. When the brain is altogether wanting, the 
bones which in the natural state serve to envelope and protect 
the cerebral mass, and are consequently in their size propor- 
tionate to its extent, do not entirely disappear, but diminish 
considerably in size, and present the same appearances as in 
those animals whose brains are naturally little developed. The 
parietal bone, for example, in a case of anencephalia described 
by M. Lallemand, consisted only of a narrow band some few 
lines in breadth. I have myself seen a similar case. Accord- 
ing to M. St. Hilaire's idea, this bone should be considered, not 
as a fragment, but as retaining its rudimentary form in conse- 
quence of having no office to fulfil in theoeconomy: it had, 
besides, its usual connexions. In this same anencephalous 
monster, the occipital bone was strangely deformed, but M. 
St. Hilaire proves, by an ingenious analysis, that it contained 
the same number of pieces, which it naturally is composed of 
at an early period of its evolution, and that, in the case under 
consideration, they only underwent a certain modification in 
their form and size, but in the essential points of number and 
connexions remained unchanged. 

Meckel is of opinion that the finger-shaped prolongation 
known by the name of diverticulum, which is sometimes found 
attached to the ilium, should be ranked amongst the supernu- 
merary parts resulting from imperfect developement. He con- 
siders this diverticulum as the vestige of the canal which, dur- 
ing the formation of the embryo, served to establish a com- 
munication between the vesicula umbilicalis and the intestine, 
or rather constituted in itself the intestine. A circumstance 
which lends considerable weight to this opinion, is, that this 
part frequently contains the remains of the omphalomesenteric 
vessels. On the other hand, this diverticulum, when existing 
in the adult, must be considered as a simple accidental forma- 
tion, by those anatomists who agree with Oken, St. Hilaire, 
and others, in assigning a different situation (the coecum for 
instance) to the origin of the intestinal canal, and its separation 
from the vesicula umbilicalis. Further observations must be 
made, and additional facts collected, before this question can 
be decided. 



100 LESIONS OF NTJTHITION. 

During the first months of foetal life, several organs which 
subsequently incline to the right or left side, occupy a perpen- 
dicular position in the median line. Thus, the heart, instead 
of the oblique direction which it afterwards assumes, is paral- 
lel to the axis of the body : so likewise is the stomach, and in- 
deed the whole intestinal tube, which, at first, consists of a 
simple canal, extending in a straight line from the stomach to 
the anus. These peculiarities of structure may continue after 
birth, and are then evidently the result of imperfect develope- 
ment. 

Lastly, to this cause may also be traced even the congenital 
anomalies of colour, which different individuals present. Thus 
the black pigment of the choroid does not make its appearance 
in the foetus until the fifth month after pregnancy ; and if at 
that period its formation does not proceed, the choroid will ap- 
pear red after birth ; as is the case in albinos. 

The greater number of malformations of the human subject 
which result from an arrest of developement, are more or less 
analogous to the natural organization of some of the lower or- 
ders of animals. This is a necessary consequence of the law, 
that man, in the several periods of his fcetal life, passes through 
the different degrees of organization which are the permanent 
condition of those animals placed beneath him in the scale of 
existence. The facts illustrative of this are so numerous that 
the only difficulty is in the selection ; we must here be content 
with pointing out some of the most striking. 

The human body, arrested in its developement, may repre- 
sent the natural structure of other animals, either in external 
form, or in the peculiar conformation of their respective or- 
gans. A very superficial examination is sufficient to convince 
us, that many of the alterations in the external form of the hu- 
man subject are found copied exactly in the inferior animals. 
For instance, the absence of the extremities, which in man 
constitutes a very great deformity, is the natural conformation 
of the cetacea and of several reptiles, and fishes. We have 
likewise additional instances of this resemblance, in those 
monsters which have, in the place of regular limbs, short 
stumps, without any trace of division at their termination ; or 



LESIONS OP NUTRITION. 101 

n less number of fingers than natural ; or fingers or toes joined 
together by a web or membrane ; and, lastly, in the presence 
of a caudal extremity, &c. 

The resemblance which may be traced between the irregu- 
lar conformation of the organs in man, and their natural forma- 
tion in other animals, is still more striking. If we take, for in- 
stance, the vascular system, we shall find cases of monstrous 
formation in which no other trace of the circulatory apparatus 
can be discovered, than a few vessels whose parietes are 
scarcely distinct ; a conformation which exactly represents the 
rudimentary state in which the vascular system naturally ex- 
ists in the zoophytes. The heart drawn out into a vessel, as 
found in some acephalous monsters, bears a strong analogy to 
the dorsal vessels of insects ; when consisting of a single cavi- 
ty with muscular parietes, it represents the simple heart of the 
Crustacea. When composed of two cavities only, it resembles 
the heart of fishes, and of several of the mollusca. When pos- 
sessing two auricles and one ventricle, it becomes the heart of 
the batrachia ; and if we suppose this ventricle subdivided into 
two by an imperfect septum, it becomes the heart of the chel- 
onea. In certain monsters, the pulmonary artery is only a 
branch of the aorta, as it is in the batrachia. In others, the 
aorta communicates with the pulmonary artery by a wide 
canal, as in the tortoise tribe. In others, again, two aortas 
arise from the heart, as is the case in birds. The nervous sys- 
tem affords a still greater number of such analogies. For in- 
stance, the prolongation of the spinal marrow to the lower ex- 
tremity of the vertebral canal, and the existence of a cavity in 
its interior, constitute the natural condition of these parts in 
the greater number of the vertebrate. The different degrees 
of developement at which the brain is arrested in anencepha- 
lous monsters, correspond almost invariably with the perma- 
nent state of this viscus in the lower animals. In some human 
monsters the spinal nerves have been found inserted into the 
membranes which invest the spinal marrow. According toM. 
Desmoulins, this disposition exists naturally in certain fishes, 
which have their nerves constantly inserted into the spinal 
membranes, without their having any communication whatever 



102 LESIONS OP NUTRITION. 

with the medulla itself. Lastly, those cases of monstrous for- 
mation in which the brain and spinal marrow are totally defi- 
cient, the sphenopalatine ganglions united, and the vertebral 
ganglions and nerves preserved, are, according to M. Serres, 
perfectly analogous to the natural state of those parts in inver- 
tebral animals. 

The greater number of the imperfections of developement 
which the alimentary canal presents, are, in like manner, an 
exact representation of the natural formation of this canal in 
other organized beings. Thus, in human monsters, the ali- 
mentary canal has often been found with only one orifice, 
generally the superior : this will be readily recognized as the 
regular formation in several zoophytes, in which class of ani- 
mals the alimentary canal represents a cul-de-sac. In fishes 
and reptiles, the cavity of the mouth is not separated from the 
nasal fossae ; in birds the communication between these cav- 
ities is only partial ; and in certain mammalia, especially the 
rodentia, it is still more confined : the musculo-membranous 
partition, (septum staphylinum,) which forms the posterior con- 
tinuation of the roof of the palate, presents a division in birds, 
and many reptiles : lastly, in several of the mammalia, the up- 
per lip is divided. These peculiarities of structure are occa- 
sionally found individually, or conjointly, in the human sub- 
ject; constituting the different varieties of hare-lip. In certain 
classes of animals, as well as in several monsters of the human 
species, the stomach is not distinct from the rest of the ali- 
mentary canal, and the latter does not present any curvature, 
&c. The kidneys, which in the adult human subject have 
been occasionally found joined together, or else divided into 
lobes, constantly present these appearances in several fishes and 
reptiles, and even in some of the mammalia. The cloaca, 
which I have already alluded to as an unnatural formation in 
the human adult, though it exists naturally in the foetus a few 
months before birth, is the regular conformation in birds and 
reptiles. The gall bladder is naturally deficient in some mam- 
malia, as the solipeda, and in several birds and fishes. The 
thymus and supra-renal capsules, which in man disappear, or 
at least diminish considerably, after birth, sometimes retain a 



LESIONS OP NUTRITION. 103 

considerable developement in the human adult : this is the nat- 
ural disposition in the rodentia, the amphibia, and in many of 
the plantigrada. 

The irregularities which the osseous system occasionally 
presents in man, are also often remarkably analogous to the 
regular forms of this system in other animals. Thus, several 
bones retain sometimes in the adult the mucous or cartilagi- 
nous character which they possessed at first in the foetus, and 
which they constantly present in invertebral animals, and even 
in some of the vertebral, as in the chondropterygious fishes. 
The division of the vertebrae, which in man constitutes a mal- 
formation, exists as the regular condition of these parts in many 
fishes. The sternum is naturally deficient in certain species of 
reptiles and fishes. The bones of the pubis, which are never 
naturally divided in the mammalia, are constantly so in birds, 
and in several reptiles. Lastly, different animals present, as 
the natural conformation of the cranial bones, a great number 
of detached pieces, which become united at an early period of 
human life, or, if they remain separate, constitute an unnatural 
formation. 

The genital organs of both sexes present few malformations 
which are not analogous to the natural state of these organs in 
other beings : such are, several of the varieties of hypospadias 
already noticed ; the uterus being two-lobed ; the penis imper- 
forate or altogether deficient ; the testicle remaining in the ab- 
domen, &c. 

There are other unnatural formations in the human subject, 
which, like the preceding, seem analogous to the regular for- 
mation in certain animals, but do not appear to have been the 
natural state of these parts at any period of the evolution of 
the foetus. Such are, for instance, certain varieties in the ori- 
gins of arteries, of which I shall have occasion to speak here- 
after, when treating expressly of the pathology of the arterial 
system. Finally, there are some malformations, which, al- 
though they are evidently the result of imperfect develope- 
ment, present no resemblance either to the natural state at 
any period of foetal life, or to the form of any of the lower 



104 LESIONS OF NUTRITION. 

animals ; such, for example, is that monstrous formation nam- 
ed cyclopia. 

Such are the most prominent facts in the history of those 
monstrosities which result from an imperfect developement of 
the organs. Let us now contrast with them those which de- 
pend on an excess of developement, or on an exuberance of 
nutrition. This may produce an increase either in the number 
or in the size of the organs. Increase of size, when affecting 
the whole body, produces those monsters called giants : when 
confined to some particular organ, it is as often adventitious as 
congenital ; in the latter case we have already seen that it fre- 
quently co-exists with atrophy of some other organ. The nu- 
merical increase of parts may be limited to a few organs, or 
may extend to every organ in the body ; the parts affected are 
in general only doubled, hence, Meckel proposes to term this 
species of malformation, duplication of organs. In several 
cases of this kind, the duplication is so complete that it is high- 
ly probable, it proceeds from the junction or incorporation of 
two foetuses. This opinion has been ably advocated in the ar- 
ticle on monstrosities by M. M. Chaussier and Adelon, in the 
Dictionaire des Sciences Medicates. 

We shall at first confine our investigations to those cases in 
which some particular organs are increased in number, with- 
out there being a tendency to the duplication of all. The bones 
are the parts which in this point of view are most important 
to examine ; because the numerical variations which they pre- 
sent, most commonly superinduce several remarkable modifi- 
cations in the number and arrangement of the muscles insert- 
ed into them, and of the nerves and blood-vessels situated in 
their immediate vicinity. According to Meckel, the vertebrae 
are, in the human subject, the bones most liable to numerical 
variations. They are likewise the part of the osseous system 
which in animals naturally presents the greatest variety in this 
respect. The increase in the number of the vertebra? is said 
to be perfect, when one or more supernumerary vertebrae ex- 
ist ; imperfect, when some portion only of a vertebra is inter- 
posed between two perfect ones, or when some supernume- 
rary part is added to a vertebra. The ribs likewise occasionally 



LESIONS OF NUTRITION. 



105 



present an increase of number ; sometimes imperfect, as when 
two ribs are united by an osseous prolongation, or a rib bifur- 
cates, and terminates at the sternum by two distinct appendi- 
ces ; sometimes perfect, in which case they present several 
varieties, relative, 1. to their connexion with the vertebrae, as 
the latter may be either increased in number or not ; 2. to 
their situation, the supernumerary ribs being situated below 
the twelfth rib, which they resemble in their disposition, or 
else placed above the first, and inserted into the cervical ver- 
tebrae, thus representing the natural conformation in fishes ; 
3. to their size ; they seldom reach so far as the sternum, and 
frequently present the appearance of small appendices at- 
tached to the vertebras ; 4. as regards their number ; they 
very seldom exceed one pair. I have already spoken, at the 
commencement of this article, of the, increase of number in 
the bones of the extremities. I also stated that the multipli- 
cation of the bones of the head was only apparent, and de- 
pended constantly on an imperfection in their developement, 
or, in other words, on the circumstance of the component 
pieces of the same bone not being united into one. 

The muscles too may increase in number, either by the pro- 
duction of additional fasciculi of fibres in the regular muscles, 
or by the formation of new muscles altogether. According to 
Meckel, almost all these varieties are analogous to the regular 
forms of the muscular system in different animals. 

If we pass on to the consideration of the internal organs, we 
shall find that in general they are not so frequently increased 
in number as the external parts : indeed this increase seldom 
takes place unless when the parts on the exterior of the body 
are likewise multiplied. This remark is particularly applica- 
ble to the organs of circulation and respiration. The diges- 
tive organs are more frequently multiplied,- without a corres- 
ponding increase in other parts of the body. The following- 
cases may be cited as examples : 1. the existence of two 
tongues, which are almost invariably placed one over the 
other ; they are seldom of the same size, and are generally 
united posteriorly in one common base : 2. a double oesoph- 
agus : 3. a double duodenum terminating in one pylorus form- 
Vol. I. 15 



106 LESIONS OF NUTRITION. 

ing a cul-de-sac: the only case of this kind on record has 
been observed in Edinburgh. 

The genital organs are very seldom increased in number. 
When this malformation does occur, the supernumerary parts 
either belong to the same sex, or to the opposite sex. In the 
latter case they give rise to different appearances of hermaph- 
rodism ; whilst in the former, they produce the duplication of 
certain organs, as the penis and clitoris. This monstrous for- 
mation, which has sometimes been observed, represents the 
natural state of these parts in didelphous animals, and in sev- 
eral of the reptile tribe. The organs are situated one over 
the other, and spring from a common root. In the male there 
is a separate passage for the urine in each penis, whilst the 
semen generally passes through but one. There is no well 
authenticated case of supernumerary testicles : Weber states 
that on one occasion he found four vesiculae seminales. Sev- 
eral authors have described cases of supernumerary mammae, 
in which three, four, or even five of these organs were found 
presenting several varieties in their size and situation. 

There are other cases in which supernumerary organs be- 
longing to different sexes are found in the same individual. The 
greater number of the following examples of this species of 
malformation have been borrowed from a Dissertation on Her- 
maphrodism, published in Germany by Steglehner. 

A. Testicles contained in the pelvis ; vesicula? seminales, 
and vasa deferentia, in their natural state, the latter opening 
into a well formed urethra ; uterus without any orifice, occu- 
pying its natural situation. 

B. Glans penis imperforate, with hypospadias. In the in- 
terior, a testicle and vesicula seminalis at one side, and at the 
other, an ovary and fallopian tube terminating in a membra- 
nous sac, which occupied the place of the uterus. In this case 
the parts of generation of both sexes were united, but were 
each in a state of imperfect developement. 

C. Penis very small, glans imperforate, testicles with the 
vasa deferentia, in the inguinal canal. Scrotum divided down 
the middle, and forming the orifice of a passage terminating 
both in a urethra and uterus. 



LESIONS OP NUTRITION. 107 

D. Uterus well formed, wanting only the cervix ; and open- 
in"- into the urethra ; neither ovary nor fallopian tube to be 
found. Penis and testicles well formed ; but each vas defer- 
ens, after passing through the inguinal canal, plunging into the 
substance of the parietes of the uterus, and after forming 
numerous convolutions there, as if to represent the vesicular 
seminales, opening as usual into the urethra. 

E. Male organs of generation, both external and internal, 
well formed, and presenting no irregularity, except that the 
testicles were contained in the pelvis. The uterus opening 
into the urethra, and having attached to it two ligamentous 
cords, without any cavity in their interior, terminating in the 
testicles, and thus resembling in their distribution the fallopian 
tubes, as the testicles resembled the ovaries by their situation 
in the pelvis. 

In the cases just enumerated, the uterus was the organ 
which was most frequently found supernumerary ; but at the 
same time the male organs of generation presented some im- 
perfection of developement ; so that these cases afford an addi- 
tional illustration of the law of compensation established by 
M. St. Hilaire. 

The urinary apparatus never presents a real numerical in- 
crease of parts?, although unnatural openings and septa fre- 
quently give it the appearance of such an increase, as we have 
already observed. 

The different organs which we have hitherto examined, may 
have their number increased without necessarily inferring the 
duplication of the entire body ; there are, however, other parts 
which very seldom have their number increased unless when 
the whole system is doubled. Of this class are, 1. the heart; 
and 2. the extremities. In some rare cases, indeed, the heart 
presents several additional parts, and even becomes perfectly 
double, although the rest of the body remains single. Thus, 
in a heart which was otherwise well formed, De Haen saw a 
species of hollow muscular appendix attached to the left auri- 
cle. Kerkringius found the right ventricle divided into two 
cavities, from each of which a pulmonary artery arose, that 
soon united with its fellow, and formed one common trunk. 



108 LESIONS OF NUTRITION*. 

Winslow relates a case, in which two hearts were contained 
in a simple thorax ; each heart was enclosed in a separate per- 
icardium ; the large vessels, both venous and arterial, were 
double at their origin, but soon coalesced into single trunks. 
It is remarkable, that in this case several organs had under- 
gone an arrest of developement : the oesophagus and trachea 
being deficient, and cyclopia existing. This double state of 
the heart, which is exceedingly rare in man and other mam- 
malia, occurs much more frequently in birds. Littre states 
that he has seen it in partridges ; Soemmering and Meckel 
have also observed it in geese. In other cases the heart is 
well formed, but gives rise to two aortas, which generally unite 
after running a short distance. In a case related by Mala- 
carne, the aorta was single, but much larger than natural, and 
furnished with five valves at its origin. The unnatural forma- 
tions of the heart, aorta, and pulmonary artery, just enume- 
rated, constitute the natural state of these parts in many animals. 
Thus, in some classes of the mollusca, the aortic heart is found 
single, with two pulmonic hearts perfectly distinct from each 
other ; in others, there are two aortic hearts found. In all 
reptiles there are two aortas, which, in some species, arise by 
distinct and separate origins from the heart, and in others, re- 
sult from the bifurcation of a single trunk. 

The multiplication of one or more of the extremities consti- 
tutes, in reality, the first degree of double monsters. In some 
cases every limb is doubled, and the individual then has eight 
extremities ; in others there is only one supernumerary ex- 
tremity ; or the multiplication may even consist in a limb, 
which at its origin is single, becoming doubled or tripled 
towards its termination ; as when two or three feet are at- 
tached to the same leg. The supernumerary limbs, whatever, 
be their number, present great varieties in their form, struc- 
ture, and point of insertion. Thus, their form is sometimes 
perfectly similar to that of the other limbs, while, in other 
cases they consist only of an appendage, or shapeless stump. 
Their structure is likewise exceedingly variable ; for they may 
contain all the parts of which the limbs to which they corres- 
pond are composed, or they may be deficient in one or more 



LESIONS OF NUTRITION. 109 

of these parts. The muscles appear to be the parts most fre- 
quently wanting, the bones being often found covered merely 
by fat and skin. Again, the bones themselves are occasionally 
found in their rudimentary state, or even .altogether deficient. 
Nothing can be more uncertain than the point of insertion of 
these supernumerary limbs. They have, in some instances, 
been found attached to one of the natural extremities, in which 
case they are very imperfect ; in others, to some point of the 
pelvis, or of the scapula. A moveable articulation is some- 
times found at the point of their insertion. 

In a great number of these cases, we can observe traces of 
the duplication of other parts. Thus, fragments of a second 
pelvis have been found attached to the regular pelvis, and it 
was to these rudimentary bones, that the additional extremity 
was found appended. In a case cited by Meckel, a species 
of sac, containing vestiges of an intestine with an anal orifice, 
extended along the thigh from the buttock to the ham ; to its 
inferior extremity was attached an arm two inches and a half 
in length, furnished with a humerus, radius, and ulna, but de- 
formed, and altogether devoid of muscles. In another case, 
also recorded in Meckel's treatise " De Duplicitate Monstro- 
rum," an irregular tumour, from which two feet projected, 
was found attached to the dorsal vertebra. It contained an 
intestine one foot in length, without any aperture, and sur- 
rounded by fat. This intestine was attached to a bone which 
bore some remote resemblance to a sacrum and in the sac 
were likewise found two tibias, together with the bones of two 
feet and one hand. 

When there are two well formed supernumerary lower ex- 
tremities, some of the internal parts are generally found 
double ; especially the intestinal tube, which divides into two 
portions, terminating each by a separate anus. The genital 
and urinary organs are also frequently double in such cases. 

Lastly, we come to those cases in which the multiplica- 
tion of different parts seems to depend on the union of two 
foetuses more or less perfectly developed. These cases may 
be divided into two classes ; the first comprehending those, in 
which a well formed foetus has, annexed to it, either a simple 



110 LESIONS OF NUTRITION. 

fraction of another foetus, or else a shapeless mass in which 
fragments of a foetus are included ; the second, those cases in 
which two foetuses seem to have been incorporated into one, 
though not so completely but that some of the parts of each 
continue distinct. 1 shall quote the following examples of the 
first of these classes from Meckel's treatise. 

On the vertex of the head of an infant in other respects 
well formed, was placed a second head, united to the first by 
its vertex, and surrounded by a neck which terminated in a 
round tumour. The infant having died at a year old, the 
heads were found to be united by an osseous suture. 

There are in the same work descriptions of other foetuses, 
to which was attached a tumour resembling an abdomen, con- 
taining within it several viscera, especially an intestinal tube, 
and occasionally presenting the rudiments of a thorax, or of a 
pelvis, with or without their respective limbs. 

In all these cases, the fragments of the supernumerary 
foetus are situated externally, being attached to the skin, cel- 
lular tissue, or some part of the skeleton ; but, in other cases, 
the fragments of one foetus are contained in the interior of 
another. One of the most remarkable cases of this kind on 
record, is related by M. Dupuytren, in the first volume of the 
Bulletins de la Faculte de Medicine. A cyst was found in the 
transverse mesocolon of a boy 13 years of age, containing an 
organized mass which, in M. Dupuytren's opinion, was de- 
cidedly a foetus. When carefully examined, it presented 
traces of some of the sensorial organs, together with a brain, 
spinal marrow, nerves, muscles, and most of the bones ; but, 
no sign could be discovered of the genito-urinary system, or of 
the organs of digestion, respiration, or circulation. It is very 
remarkable, that in a case where the osseous system was so 
well developed, there should have been no trace of an intes- 
tinal tube, although the formation of the digestive apparatus is 
considerably prior to that of the skeleton. With the knowl- 
edge we now possess of the laws which regulate the evolution 
of the embryo, the circumstance of one foetus being contained 
within another is not more difficult to conceive, than the fact 
of their being united externally. The reader who wishes for 



LESIONS OF NUTRITION. Ill 

further information on this subject, may consult the Thesis of 
M. La Chaise, De la Duplicite Monstrueuse par inclusion, de- 
fended before Beclard in 1822 ; also, an interesting essay on 
the same subject recently published by M. Olivier. 

The second class comprehends the three following divisions: 
1st. the body double, the head being single ; 2d. the head 
double, the body being single ; 3d. both head and body 
double. 

The first division may be comprised under the generic ap- 
pellation of monocephalous monsters with two bodies. In some 
of those cases, the separation of the bodies is only complete 
inferiorly ; all the double parts from the umbilicus upwards, 
manifesting a disposition to coalesce : in others, the separation 
is perfect as high as the neck. The most remarkable circum- 
stance, however, in these cases, is, that the head, although 
single, almost invariably presents on dissection some supernu- 
merary parts, which seem to indicate a disposition in that or- 
gan to become double, as well as the other parts of the body. 
The natural conclusion from these appearances is, that the two 
foetuses continued separate inferiorly, whilst they were con- 
founded together superiorly ; in conformity with which sup- 
position, we find, that, in addition to the regular bones which 
enter into the composition of a well formed cranium, others 
are, in these cases, superadded, which serve to constitute the 
rudiments of a second head, and generally observe the fol- 
lowing arrangement : the occipital and temporal bones are 
those which attain the greatest degree of developement, while 
immediately before them is situated a confused mass of small 
bones, without any determinate shape, which appear to be the 
rudiments of the anterior part of the skull and face ; from 
which arrangement we may reasonably infer that the two 
heads were placed one before the other, and that the posterior 
one was arrested in its developement. Within the skull, we 
also find traces of a second head ; thus, the brain, which at its 
anterior part is single, presents posteriorly one or more super- 
numerary parts ; the cerebellum, for instance, being not un- 
frequently found double, thus answering to the existence of a 
double occipital. The rest of. the skeleton, as high as the 



112 LESIONS OF NUTRITION. 

neck, is to a greater or less degree double in all its parts. 
Each thorax contains two well formed lungs ; there are also 
two tracheas, and two larynxes, often surmounted by but a 
single epiglottis. In general there are likewise two hearts, 
which are not constantly of the same size ; the two ascending 
aortas unite into one, before giving off the arteries to the 
head. In some cases, however, there is only one heart, situ- 
ated in the middle of a double thorax : the vessels rising from 
it then give off a double set of branches. The arrangement 
of the alimentary canal varies according to the condition of 
the superior parts of the body. Thus, we sometimes find, 1. 
a single mouth, and immediately behind it, all the parts double ; 
as, two tongues, two cesophaguses, &c. ; 2. the alimentary 
canal simple as far as the insertion of the oesophagus into the 
stomach ; 3. the stomach itself simple, and the rest of the 
intestinal tube double ; 4. and lastly, the small intestine simple, 
until we arrive near the point of its insertion into the caecum. 
The liver in some cases is single, but remarkably large, and 
provided with two gall bladders ; in others, there are two 
livers perfectly distinct from each other. The spleen and 
pancreas, as also the genital and urinary organs, have been 
found double in all the cases of this description which have as 
yet been recorded. The extremities are sometimes all doub- 
led, and naturally formed ; in other cases there are only two 
perfect upper extremities, whilst a third, either imperfectly 
developed, or else composed of two incorporated together, is 
attached to the point of contact of the two bodies : the lower 
extremities present the same anomalies. 

The second division comprises monsters with two heads and 
a single body (dicephali). This class likewise presents seve- 
ral varieties. 1. The head may be single posteriorly, and 
double anteriorly ; in which case there is only one skull, but 
there are two faces, more or less perfectly formed, placed side 
by side, and separated by a longitudinal division. The nose 
is in this case invariably double, and Meckel states that the 
mouth has never been found single except in one solitary in- 
stance. Each face is provided with a pair of eyes ; in one 
case, however, there were only three eyes altogether, but one 



LESIONS OF NUTRITION. 113 

of them was placed in the median line, and seemed formed 
by the union of two, as in the case of clycopia. The number 
of ears is variable ; in some cases four have been found, with 
the two intermediate separate or united ; in others, three, and 
in others, only two : in general each face presents some im- 
perfection in the side which corresponds with its neighbour. 
2. The two heads may be completely separate throughout their 
whole extent, and perfect in every point. Sometimes, how- 
ever, the heads are united at their posterior surface by a deli- 
cate membrane ; this may be considered as an intermediate 
degree between the preceding variety and the present. 3. In 
the two preceding varieties, the heads alone were double, but 
in this the neck also presents the same anomally. 4. The 
head and neck being double, a supernumerary upper extremi- 
ty is interposed between them. The structure of this ad- 
ditional limb is exceedingly variable, as it may contain either a 
double or a single humerus, the latter thicker than usual, a 
double radius, a hand with two thumbs, or with supernumera- 
ry fingers, or else two hands attached to a single forearm, and 
arm : the limb itself has been found connected with a scapula, 
which is also occasionally double. 5. The head being double 
in one of the preceding degrees, and the upper extremities 
presenting their natural form and number, there may be three 
lower extremities. In this case, which is of rare occurrence, 
the supernumerary limb is sometimes found attached to one of 
the lateral portions of the pelvis, which at the same time gen- 
erally presents some tendency to duplication. 6. The upper 
extremities may be perfectly double ; in which case the heads 
are not placed side by side, but face to face. Lastly, the 
lower extremities also may be double. Here the supernume- 
rary limbs are sometimes perfect, but are more frequently 
imperfectly developed, and may consist, for instance, of simple 
excrescences of a few inches in length attached to the nates, 
and terminating in one, or two toes at most. 

In all these varieties of double headed monsters, although 

the body appears single externally, yet, when we examine its 

internal structure, we find that several organs are double, and 

that, in proportion to the degrees of separation between the 

Vol. I. 16 



114 



LESIONS OF NUTRITION. 



two heads and necks, and to the number of supernumerary 
entremities. Thus, the vertebral column, which in the majority 
of these cases is double only in the cervical region, may be 
bifurcated throughout its whole extent, or as far, at least, as 
the lumbar region. The several bones which enter into the 
composition of the pelvis, may likewise have their number 
doubled. Two hearts have been also found ; most commonly 
they are contained in a single pericardium ; the vessels distrib- 
uted to the upper parts of the body are constantly increased 
in number. The organs of respiration have, in like manner, 
been found double. The portion of the alimentary canal situ- 
ated above the diaphragm, the stomach, and even the intestine, 
are constantly double ; the latter, however, towards its inferior 
extremity becomes single, and opens externally by a single 
anal orifice. The liver is invariably simple, but yet larger than 
usual, and in many cases furnished with a double gall bladder. 
There are frequently two spleens. The kidneys may either be 
simple, or may offer some traces of an approach to duplication ; 
as when, in addition to the two kidneys occupying their natu- 
ral position, two others are found united into one, and situated 
on the vertebral column. In another case, four kidneys were 
found, but two of them were exceedingly small, and destitute 
of ureters. The organs of generation, and the urinary bladder, 
are most commonly simple and well formed. 

Thus, then, it would appear, that, as in those monsters which 
have two bodies and a single head, the head frequently pre- 
sents unequivocal traces of its being formed by the incorpora- 
tion of two heads, so likewise in the case of two-headed mon- 
sters with single bodies, the body is in fact but apparently sim- 
ple, and when carefully examined, exhibits several of its organs 
in a state of duplication. 

The last variety of double monsters which we shall enume- 
rate, is that in which all the grand cavities are separate, at least 
externally ; where, in short, there are two heads and two 
bodies. In this variety, the extremities occasionally present 
some anomalies ; for instance, one of the lower extremities has 
been observed in merely a rudimentary state, attached as an 



LESIONS OF NUTRITION. 115 

appendix to the thigh of its fellow, which was well formed : 
while the leg belonging to this latter had seven toes on its foot. 
The junction of the fetuses may take place at any point of 
the body ; and, accordingly, they have been seen attached to 
each other ; 1st, by the crown of the head, in the same right 
line ; 2d, by the anterior portion of the thorax ; 3d, by the 
anterior portion of the abdomen ; 4th, by the dorsal spine ; 5th, 
by the sacrum ; 6th, by the nates, &c. The point of junction, 
wherever situated, presents two important varieties ; in the 
one, the attachment is superficial, being effected only by the 
skin, and the bones ; in the other, it is more deeply seated, the 
cavities at the point of union, though in appearance distinct, 
being, in fact, converted into one, and some of their organs 
having a tendency to become incorporated at the same point. 
If, for instance, the two foetuses are joined together by the 
anterior portion of the thorax, the sternum may be altogether 
deficient ; in which case, both thoracic cavities are thrown into 
communication, and the viscera they contain present several 
anomalies in their form and arrangement. Sometimes there 
are two hearts perfectly distinct, enclosed each in its own 
pericardium ; sometimes the hearts, though both well formed, 
are contained in one common pericardium, in which they may 
be either distinct from each other, or superficially joined to- 
gether at a single point, or through their whole extent ; the 
uniting medium being either composed of cellular tissue or of 
their muscular substance. In other cases, though two hearts 
are still found, yet, neither of them is perfect in its form or 
structure. Lastly, there may be only one heart, presenting 
several varieties of conformation. It has been observed in one 
case composed of four distinct ventricles ; in another, it pre- 
sented the natural number of cavities, but the left ventricle 
was much larger than usual, and divided by a septum into two 
compartments. From one of these compartments arose the 
aorta belong to the left foetus, which gave oflt the pulmonary 
artery to the same individual ; from the other compartment 
arose a small trunk communicating with the aorta of the right 
foetus, which arose from the right ventricle, and likewise gave 
off the pulmonary artery— (Meckel). In other cases of this 



116 LESIONS OP NUTRITION. 

description the heart was well formed, but the large vessels 
were all double, so that two aortas sprung from the left ventri- 
cle, «fec. Finally, in some monsters of this class, the heart, so 
far from being double, is reduced to an unnatural degree of 
simplicity in its structure. In the centre of a double thorax, 
united so as to form a single cavity, a solitary heart has been 
found, composed of but one auricle and ventricle ; the pulmo- 
nary arteries were given off by the aorta, which did not divide 
until at a considerable distance from its origin : in another 
case, which, as well as the preceding, is recorded by Meckel, 
there were two auricles, and but one ventricle, which was 
divided by an imperfect septum ; from the principal cavity of 
the ventricle arose two aortas, and from the lesser compart- 
ment, two pulmonary arteries. 

When the foetuses are attached by the abdomen, the intesti- 
nal tube is occasionally found single, in some part of its extent : 
sometimes there is only one liver, in which case it is very 
large, and often composed of several lobes, and furnished with 
two gall bladders. 

If the point of junction is situated at the very bottom of the 
abdomen, the different parts which constitute the parietes of 
the pelvis, or are contained in its cavity, are more or less con- 
founded together. In such cases there is sometimes only one 
anus for both bodies, or only one set of genital organs. The 
varieties which the bones of the pelvis present are not less re- 
markable, they being sometimes supernumerary, and some- 
times, strange as it may appear, altogether deficient. When 
this occurs, the lower extremities are either wanting, or are 
only imperfectly developed, and attached to the base of the 
vertebral column by small osseous fragments. 

We have already seen, that, from various causes more or 
less appreciable, the nisus formativus may be either increased 
or diminished ; thus producing the two grand classes of mon- 
strous formations resulting from excessive, or imperfect devel- 
opement, which have hitherto engaged our attention in this 
chapter. This force, however, is not only liable to increase 
or diminution, but is also capable of being perverted, or (if I 
may use the expression) set astray. From this perversion of 



mmmmmr 

LESIONS OP NUTRITION. 117 



the nisus formativus result another class of monstrous forma- 
tions, which exhibit neither a deficiency nor an excess of de- 
velopement, but simply an unusual disposition of one or more 
organs. One of the most striking examples of this class is ex- 
hibited in the general transposition of the thoracic and abdom- 
inal viscera ; in which all those parts usually situated at the 
right side are found at the left, and vice versa. The heart af- 
fords a remarkable illustration of this transposition ; its apex, 
instead of pointing towards the left, corresponds to the interval 
between the fifth and sixth ribs of the right side ; its auricles 
and ventricles occupy a position exactly the reverse of their 
ordinary situation ; and the aorta descends along the right side 
of the vertebral column. The left lung is divided into three 
lobes, whilst the right has only two. The pyloric orifice of 
the stomach is turned towards the left hypochondrium, which 
is occupied by the liver, the spleen being at the right side. 
The whole intestinal tube presents a similar transposition ; thus 
the caecum rests on the left iliac fossa, &c. 

This general transposition can only be explained by suppo- 
sing an aberration from the natural manner of developement, 
in the original formation of the different organs. It is impor- 
tant to remark that, during the earlier periods of the evolution 
of the foetus, several organs which subsequently incline to the 
right or left side, commence by being perpendicular, and situ- 
ated in the median line of the body : such is the original posi- 
tion of the heart and stomach, and even of the liver, which, at 
the commencement of foetal life, extends as far to the left as 
to the right side. The knowledge of this anatomical fact en- 
ables us to understand more readily how those organs once 
situated on the median line, may at a subsequent period in- 
cline to one side rather than the other ; although we are as 
yet unable to ascertain the causes which influence this irregu- 
lar determination. 

To this same class of malformations should likewise be re- 
ferred the many anomalous varieties observed in the origins of 
arteries and veins. Of these, we shall only notice the most 
remarkable, as the minor anatomical varieties scarcely merit 
the appellation of malformations. 



118 LESIONS OF NUTRITION. 

The heart, in other respects well formed, may have two 
aortas arising from its left ventricle, and the pulmonary artery 
may be a branch from the aorta. Beclard and J. Cloquet 
have seen two superior venae cavae, perfectly distinct, opening 
separately into a single right auricle. The arteries which 
arise from the arch of the aorta present several irregularities 
in their origin, which have been carefully described by Meckel, ] 
and faithfully represented by Tiedemann. These irregulari- 
ties are chiefly numerical, and, most commonly, the number is 
increased ; as when the right subclavian arises immediately 
from the aorta, or when the aorta gives off branches which 
do not usually arise from it, such as the vertebral, inferior 
thyroid, or internal mammary. These arteries may likewise 
present several varieties in the points at which they arise, the 
directions which they follow, and the mutual relations they 
bear to each other. The diminution in the number of trunks 
furnished by the arch of the aorta results from the Union of 
two arteries which are usually separate ; as when the left car- 
otid is given off by the innominata, or arises from the aorta 
by a common trunk with the left subclavian ; or when one 
common trunk furnishes the two carotids, and another, the 
two subclavians ; or, lastly, when the right subclavian arises 
singly at its usual place, and another trunk gives off the left 
subclavian, and the two carotid arteries. In other cases, the 
number of trunks arising from the arch of the aorta is neither 
increased nor diminished, but their origin is modified and al- 
tered ; as when there is no arteria innominata, and each sub- 
clavian arises separately from the aorta, but there is a common 
trunk for the two carotids ; or when the carotid and subclavi- 
an arteries arise separately at the right, and the innominata, 
is at the left ; or when the innominata, situated at its usual 
side, gives off the left carotid ; in this case the number of ar- 
teries springing from the arch of the aorta is still the same, 
for the place of the carotid is occupied by one of the verte- 
bral arteries, which arises directly from the aorta. 

The last anomaly which we shall notice is an alteration, to 
a greater or less extent, in the relative position of the three 
vessels which naturally arise from the aortic arch ; as, when 



LESIONS OP NUTRITION. 119 

they are at a greater distance from each other than natural, 
or, on the contrary, are more closely approximated ; in this 
latter variety they sometimes show a disposition to coalesce, 
thus forming an intermediate step towards the anomalous for- 
mation in which two or more trunks, usually distinct, become 
conjoined. It is a remarkable fact, that several of those anom- 
alous varieties in the origin of arteries, which we have just 
enumerated, constitute the natural and regular condition of 
these vessels in certain animals : thus, in birds, the left carotid 
generally arises by a common trunk with the left subclavian, 
&c. Since we have learned how little the qualities of the 
blood depend on the situation of the origins of the arteries, 
these varieties have lost much of their importance in a physi- 
ological point of view ; as the only influence which they pro- 
duce on the circulation is limited to some modification of its 
velocity. It may be received as a general law that all ar- 
teries are detached from their trunks, at the nearest possible 
point to their respective organs, so that if the congenital posi- 
tion of any organ be altered, its artery likewise undergoes a 
corresponding alteration in the place of its origin, which, as I 
before remarked, is invariably at some point near the organ to 
which it is distributed. For instance, in an individual in whom 
I found the right kidney lodged in the pelvis, the renal artery 
of the right side was given off by the hypogastric. 

If the interpretation which we have given to the facts ad- 
duced in this chapter be correct, we must adopt the general 
conclusion, that the greater number of monstrous formations 
may be referred to vices of developement, and, consequently, 
do not require for their explanation any hypothesis of previous 
disease having affected the foetus. In the first place, this cause, 
which several authors would have us consider as almost the ex- 
clusive agent concerned in the production of monsters, is alto- 
gether inadmissible in those malformations which proceed from 
an excess in the number, or size of the parts : neither can it 
afford us any clue to those congenital transpositions of differ- 
ent organs, which we have already alluded to. As to those 
monstrosities which depend on a deficiency of parts, it would 
be absurd to deny that they ever can proceed from the acci- 



120 LESIONS OF NUTRITION. 

dental destruction or alteration of the parts by some disease 
affecting the fetus. No doubt, certain cases of anencephalia, 
hydrocephalus, encephalocele and atelomyelia, are to be refer- 
red to a morbid accumulation of serum in the interior of the 
skull, or spine ; indeed this fact has been clearly and satisfac- 
torily established by the recent researches of Professor Duges. 
M. Velpeau states that he has had opportunities of examining 
foetuses born before their full time, in which different parts of 
the body, such as legs or arms, and parts of the face, were in 
a manner decomposed, and partially detached from the trunk, 
as if they had been seized with gangrene. It is highly prob- 
able, that, ere long, the separation would have been complete, 
and that the fetus would thus have come into the world, want- 
ing certain parts, which were at first naturally formed, but sub- 
sequently became diseased, and, by the ordinary process of 
gangrene and separation, were ultimately detached from the 
body. In the majority of cases, however, this explanation is 
inadmissible, and the different malformations above enume- 
rated can only be accounted for, by supposing an arrest in the 
progress of their developement. This subject has been already 
so fully discussed in this chapter, that I shall not at present en- 
ter into any additional details ; but refer the reader who may 
wish for further information on the subject, to the excellent 
article on anencephalia, by M. Breschet, in the Dictionaire de 
Medicine. 

M. St. Hilaire, who has so ably advocated the doctrine that 
monstrous formations proceed from faults of developement, or, 
in other words, from a derangement of the nisus formativus, 
admits the influence of mechanical causes, in certain cases. 
He is of opinion, that unnatural adhesions, formed between the 
foetus and its investing membranes, at a period when the or- 
gans are as yet in their rudimentary condition, may have the 
effect of altering their natural situation and direction ; and, 
likewise, by turning towards the placenta a portion of the blood 
destined for the fcetal organs, may thereby produce an arrest 
in their developement. If to this doctrine, it be objected, that 
the malformations are not confined to the surface of the body, 
but are likewise found in its interior, M. St. Hilaire replies, 



LESIONS OF NUTRITION. 121 

that there has been a period in the evolution of the fetus, 
when these organs were exterior, and consequently suscepti- 
ble of contracting adhesions with the placenta : that, if these 
adhesions continue, the organs remain superficial, and the par- 
ietes of their respective cavities, which are generally subse- 
quent in their formation to the organs they enclose, are in such 
cases not formed at all ; but that, if from the increased weight 
of the fcetus, or any other accidental circumstance, these adhe- 
sions be ruptured, the organs whose developement they had 
impeded are no longer found protruding from their cavities, 
but still remain in a state of imperfect developement, because 
the natural period of their evolution had gone by. 

The number of observations and facts by which this theory 
is, as yet, supported, is too inconsiderable to warrant its gen- 
eral application : at present it can only be admitted as applica- 
ble to some particular cases of monstrous formation. 

If monstrosities be the result of a fault of developement pro- 
duced by external mechanical causes, it is evident, that we 
must possess the power of preventing the regular develope- 
ment of the fcetal organs, and of producing at pleasure certain 
malformations, by artificially modyfying the condition of the 
embryo at different periods of its existence. This experiment 
has been tried by M. St. Hilairc. He caused several eggs to be 
hatched, some of which had been previously varnished in dif- 
ferent parts, and others, enveloped wholly, or partially, in gold 
beaters' leaf, while others, again, had had their shells perfora- 
ted by various means. At the expiration of the usual period 
of incubation, it was found, that in some the chicken was not 
all developed ; in others, it had not attained its natural size ; 
whilst in some instances its growth was quite preternatural. 

In another series of experiments, he endeavoured to modify 
the organization of the chick, by perforating, striking, or sha- 
king the eggs, at different periods of their incubation. We have 
not, as yet, been made acquainted with the results of these ex- 
periments. 

It is highly probable, that the developement of many of the 
organs of the foetus is considerably influenced by the quantity 
and quality of the nutriment which it receives. This conjec- 
Vol. I. 17 



122 LESIONS OF NUTRITION. 

ture derives considerable support from the very interesting ex- 
periments made on bees by M. Hubert of Geneva, in which 
he succeeded in producing at pleasure males, females, or neu- 
ters, by placing the young insect in a cell containing a greater 
or less supply of honey. 

Several authors have enumerated, amongst the causes of 
monstrous formations, various degrees of pressure made on the 
foetus, by tumours attached to the parietes of the uterus, by a 
second foetus, or by a mass of hydatids, &c. Others, again, 
have attributed these malformations to certain varieties in the 
form and distribution of the umbilical cord. But, in the pres- 
ent state of our knowledge, though we cannot altogether reject 
the influence of any of these causes, we must consider them as 
playing a very secondary part indeed, in the production of the 
various monstrosities. It appears to me quite unnecessary to 
enter into a formal refutation of the antiquated superstition of 
the vast influence which the imagination of the mother exerts 
over the developement of the foetus ; an opinion founded only 
on rude resemblances sometimes existing between certain mal- 
formations, and frightful objects which may have disturbed the 
mind of the mother during pregnancy. I am not, however, 
prepared to deny that a strong moral emotion felt by a preg- 
nant woman, may exert some influence on the nutrition of the 
foetus in her womb, and to a certain extent arrest or pervert 
its developement. The influence of such causes is, however, 
much weaker than might, a priori, be supposed ; for, we have 
examples occurring every day, of women suffering under the 
most violent moral emotions, and yet producing well formed 
children; and, on the other hand, of women bringing monsters 
into the world, without having experienced a single moment's 
uneasiness during the whole period of pregnancy. 



LESIONS OF NUTRITION. 123 



CHAPTER II. 

Lesions of Nutrition with respect to the Number of the Mole- 
cules composing the different Solids. 

The number of the constituent molecules of any solid, may 
be either increased or diminished. An increase of their num- 
ber seems to indicate an exuberance of the nutritive powers 
of the part, as is expressed by the term hypertrophy, used to 
signify this particular alteration. On the other hand, the di- 
minution in the number of these molecules appears to proceed 
from a deficiency of the nutritive powers ; hence the term 
atrophy has been adopted to express the condition of a solid, 
which receives less nourishment than natural, or which, when 
its nutrition is totally suspended, becomes at last completely 
obliterated. 



ARTICLE I. 

Hypertrophy. 

This term, which has been not many years adopted into 
medical language, was at first restricted in its application, to 
the preternatural increase of nutrition of the thyroid gland, the 
heart, and the muscles of animal life ; its signification has of 
latter years been considerably extended, as the investigations 
of modern pathologists have clearly ascertained, that there is 
not a single tissue or organ in the body, which is not liable to 
this affection ; so that hypertrophy may now be justly consid- 
ered one of the most frequent alterations of nutrition, as well 
as one of those which occasion the greatest variety of function- 
al derangements. It is not, however, simply by its presence 



124 LESIONS OF NUTRITION. 

in some part of the body (as is the ease with various morbid 
secretions) that hypertrophy produces an injurious effect on 
the system ; for its influence is only felt when it disturbs any 
of those functions which cannot be deranged with impunity. 
Thus, hypertrophy cannot be considered as a disease, when 
seated in a muscle of the animal life ; but, when affecting the 
heart and deranging its functions, it constitutes one of the most 
formidable diseases. 

The term hypertrophy should be applied exclusively to those 
cases in which the tissue whose volume is increased retains 
its natural structure and organization ; and not to those lesions 
in which the increase of volume is owing to other causes than 
the mere increase of number of the molecules of the tissue. 

This affection may be studied, 1. in the several elementary 
tissues : 2. in the organs which are formed by the combination 
of these tissues. Under the influence of certain causes which 
I shall endeavour to appreciate at the conclusion of this chap- 
ter, we frequently observe various portions of the cellular 
tissue interposed between the different organs, become affected 
with hypertrophy ; in which case it undergoes a variety of 
alterations in its sensible qualities. Thus, in those parts where 
it naturally possesses but little consistence, and resembles a 
sort of organized mucus, it acquires when hypertrophied a 
greater degree of firmness and density; and, in the parts 
where its density is naturally considerable, its laminae and fila- 
ment acquire an unusual thickness, become blended together, 
assume a dull white colour, or a peculiar grey semi-transparent 
appearance, and offer considerable resistance to the scalpel. 
When the hypertrophy has arrived thus far, we observe be- 
tween the organs, or the different parts of the same organ (ac- 
cording to the seat of the disease) a whitish substance in the 
form of laminae, or of irregular masses, intersected by numer- 
ous lines and striae ; and, if we examine the structure of these 
masses, and trace their formation, we find that they are evi- 
dently composed of portions of cellular tissue, which become 
progressively more and more condensed, and finally present 
the appearance of a homogeneous mass, which, according to 
its colour and degree of condensation, resembles either the 



LESIONS OP NUTRITION 125 

interior of a turnip, with its dull white striae in a greyish paren- 
chyma ; the fat of bacon ; or imperfect cartilage, such as is 
found in the fetus. 

These different varieties of hypertrophy of the cellular tex- 
ture have hitherto been erroneously, as I conceive, attributed 
to the developement of an accidental production, a new tissue 
to which there is nothing analogous in the healthy state ; 
whereas they will in general be found to depend on a preter- 
natural increase of the nutrition of the cellular tissue, the 
original and common basis of all organized matter. It is to 
this hypertrophied cellular tissue, disposed in striae, laminae, 
or rounded masses, the term scirrhus is applied, when it is 
grey and semi-transparent ; and encephaloid, when its colour 
is of a dull white ; in consequence of a rude resemblance sup- 
posed to exist between the advanced stages of this tissue (the 
encephaloid) and the substance of the brain. For my own 
part, I confess that I have never been able to establish any 
real or definite distinction between those two accidental tis- 
sues, nor do I think that others have been more successful. 
In the dead body we constantly see them united and confound- 
ed together, as indeed might a priori be expected, inasmuch 
as they are both simple varieties of the same morbid altera- 
tion, namely, hypertrophy of the cellular tissue ; in some cases, 
simple and uncombined, in others, conjoined with some pro- 
product of a morbid secretion into the areolae of the cellular 
texture. 

That peculiar variety of cellular texture which, when drawn 
out into the form of a membrane, constitutes serous tissue, has 
not as yet been found in a state of hypertrophy ; but an exu- 
berance of nutrition has frequently been observed in the cel- 
lular texture which lines the delicate pellicle, or sort of inor- 
ganic epidermis, termed serous membrane. 

The tegumentary tissues, both mucous and cutaneous, are 
often affected with hypertrophy : in some cases the whole tis- 
sue is hypertrophied ; in others some only of its anatomical 
elements experience this alteration. Thus, in the nervous 
membranes, we occasionally observe the hypertrophy con- 
fined, 1. to the substance of the mucous tissue ; 2. to its vil- 



126 LESIONS OF NUTRITION. 

losities ; 3. to its papillse ; 4. to its crypts or follicles. Thus, 
in like manner, in the skin, the hypertrophy may affect exclu- 
sively the cutis vera or dermoid tissue properly so called, the 
follicles which it contains, the papilla? which arise from its 
surface, or the different layers which, taken together, consti- 
tute the corpus mucosum of Malpighi. There are certain 
morbid conditions, which, by producing the hypertrophy of 
some one of these constituent portions of the cutaneous tissue, 
serve admirably to demonstrate its existence, and to throw 
more light on it ; such is the following case : 

A woman, seventy-four years of age, died of phthisis, in the 
hospital of La Charite, with several tuberculous cavities in her 
lungs. She had formerly had an ulcer on her right leg, but 
for the last thirteen years the sore had cicatrized, while the 
limb had gradually acquired an extraordinary developement. 
It was swollen and hard, and the skin was rough, and mostly 
of a yellowish brown colour, not unlike the shade observed on 
the cubital margin of the hands of negroes; in some points its 
colour was considerably darker, approaching to black. After 
death I proceeded to examine the limb. Neither the arteries 
nor veins presented any appreciable trace of disease, in the 
texture of their parietes, or in the sensible qualities of the blood 
which they contained. The subcutaneous and intermuscular 
cellular tissue was remarkably developed, and even indurated. 
I was struck with the perfect resemblance it presented to the 
submucous cellular tissue of the stomach, when, being indu- 
rated and infiltrated with concreted albumen, it has under- 
gone that peculiar degeneration termed scirrhus. It still how- 
ever contained, in certain parts, a considerable number of 
fatty lumps. The density of the tissue increased considerably 
as it approached the corium or cutis vera, which was likewise 
much thicker than natural, and in several points it was utterly 
impossible to establish a precise line of demarcation between 
the thickened corium, the aponeurotic filaments which ter- 
minated in it, and the indurated cellular tissue, which was ap- 
plied to its internal surface ; indeed all these parts seemed to 
be merely difFerent degrees of one and the same organization. 



LESIONS OF NUTRITION. 



127 



The colour of the corium was not at all altered, nor were its 
capillary vessels injected. 

Above the cutis vera, I observed, 1. the papillae remarkably- 
developed in several points and quite separate and distinct 
from the subjacent cutis ; 2. immediately over the papillae 
three layers, more or less distinct according to the points 
where the examination was made ; 3. the epidermis. 

The papillary tissue (bourgeons sanguinis of M. Gautier) pre- 
sented in some points its usual appearance and dimensions ; 
but in others, the little cellulo-vascular bodies of which it is 
composed were so elongated, that they might readily be mis- 
taken for those whitish appendices which are attached to the 
mucous membrane of the tongue and mouth in several species 
of birds. These papillae were united into groups, between 
which was interposed a denser and a whiter tissue, which, on 
one side, was continuous wit! 1 the corium, and, on the other, 
terminated in a whitish layer, tu be presently described, form- 
ing a line of separation between the papillary tissue and those 
parts of the cutaneous tissue more superficially seated (the 
rete mucosum of Malpighi and the Epidermis). In some other 
points, those elongated papillae could not be detected ; but in 
their place I observed a wrinkled layer which seemed formed 
by this same papillary tissue, with this difference, that the 
papillae were so swollen and crowded together, that they had 
quite lost their characteristic appearance. It was easily sep- 
arated from the corium, which beneath it presented a remark- 
ably smooth, polished appearance. 

From these observations it follows, that the cutis is essen- 
tially composed of two parts, the corium and the corpus papil- 
lare, which, though confounded together, may nevertheless 
be perfectly isolated and separated one from the other, in cer- 
tain morbid conditions. The mucous membrane which lines 
the intestines presents the same appearance ; for the innu- 
merable villosities with which its internal surface is studded 
form a distinct layer, which in certain diseases may readily 
be detached from the subjacent mucous membrane without 
producing any solution of its continuity. 



128 LESIONS OF NUTRITION. 

Over the papillary surface, and interposed between it and 
the epidermis, we found three layers perfectly distinct from 
each other ; but there was a considerable difference in the 
degree of their developement at different points. The first 
layer which presented itself, proceeding from within out- 
wards, appeared like a delicate white line, which, as it dipped 
in between the papilla?, assumed an undulating appearance ; 
we could not trace any vessel ramifying on it, and it seemed 
altogether composed of a cellulo-fibrous tissue. It was not 
equally distinct all through. This layer appears to me evi- 
dently analogous to that described by M. Gautier, in the skin 
of the heel of the negro, under the name of the deep seated 
white layer, and by M. Dutrochet as the epidermic layer of the 
papillce. 

Immediately over the undulating line just described, or, in 
those points where this line was not directly visible, (of which 
there were several,) immediately over the papillary surface, 
appeared another layer, differing from the preceding in its 
colour, which was of a greyish brown, or black, according to 
its situation. When cut vertically, there was nothing to be 
seen but an apparently homogeneous stratum presenting dif- 
ferent shades of colour ; but when sliced obliquely with a 
razor, it presented quite a different appearance, and seemed 
composed of a network, formed by exceedingly delicate 
blackish filaments, crossing each other in every direction, and 
leaving between them several transparent intervals through 
which the white parts underneath were visible. This reticular 
layer was evidently analogous to the coloured layer in ne- 
groes. I think it necessary, however, to state, that, notwith- 
standing the most minute examination, I could not succeed in 
observing it composed (as described by M. Gautier) of a se- 
ries of small bodies, of the form of segments of a sphere, 
lying closely together, which he has called gemmules. On the 
contrary, I could distinguish nothing in this layer, though very 
distinct, except a delicate network, such as is presented by 
certain leaves when dried and deprived of their parenchyma : 
neither was this the first opportunity I had of remarking this 
network charged with colouring matter ; for I had previously 



LESIONS OF NUTRITION. 



129 



observed it most distinctly after the application of a blister 
to the thorax of a negro. It is an interesting calculation, 
whether those filaments, which by their interlacement consti- 
tute this network, should be considered as vessels which exist 
naturally in the white as well as the black man, but in the 
former are never charged, unless accidentally, with colouring 
matter; and whether they are the vessels which in jaundice are 
filled with the yellow colouring matter ? An important fact, 
which in such speculations as the present should not be for- 
gotten, is, that the secretion of the black colouring matter is 
not so entirely dependant on any special arrangement of or- 
ganization, as to be found exclusively in that layer of the cutane- 
ous tissue where it exists naturally in the black, and where, in 
the white, it is occasionally produced by disease. In confir- 
mation of this observation I may remark, that, in a few days 
after examining the skin which forms the subject of this para- 
graph, I had occasion to examine a portion of the skin of an- 
other individual, the surface of which was studded over with 
a number of small black spots, that on examination were 
found to depend on a black colouring matter interposed be- 
tween the corium and epidermis, and evidently unconnected 
with either the one or the other. Similar spots produced by 
the same cause were also found scattered up and down in the 
substance of the corium, and in the subcutaneous cellular 
tissue ; hence it would appear as if the simple fact of a 
healthy secretion having become a morbid one, were suffi- 
cient to release that secretion from the necessity of appearing 
exclusively in its natural situation. Accordingly, similar dis- 
positions of colouring matter have occasionally been found in 
every tissue in the body. Be that as it may, the preceding 
description proves the accidental developement of a coloured 
layer in the white subject, precisely in the same situation 
where it is said to exist naturally in the negro ; and little 
doubt, can, I think, be entertained, that it was the colouring 
matter contained in this layer, which produced the partial 
coloration of the skin of the limb affected with elephantiasis. 

As we prosecuted the dissection, the epidermis appeared at 
several points in immediate contact with the layer last de- 

Vol. I. 18 



130 LEISONS OF NUTRITION. 

scribed, from which it could be separated by putrefaction with- 
out receiving the least stain from it ; but, at other points, an- 
other layer appeared interposed between the epidermis and 
the coloured layer, presenting different situations. In some it 
was a delicate white layer, analogous to the epidermic layer 
of the papillae ; in others, its thickness was much more con- 
siderable, and at the same time it acquired a greyish colour, a 
considerable degree of hardness, and a true horny consistence, 
and in some places was composed of a series of scales placed 
one above the other, in an imbricated manner. Where this 
latter disposition existed, the innermost scale was generally 
sustained by a cluster of papillae preternaturally developed. 
From these details, no doubt can be entertained that this third 
layer, situated immediately under the epidermis, was analo- 
gous to that described by M. Gautier, as existing in the negro, 
and which he named the superficial white layer. This layer 
exists only as a rudiment in man, but in animals is more per- 
fectly developed, for the production of the various species of 
shell and horn ; it has in consequence received from M. Du- 
trochet the more scientific appellation of the horny layer. 

Thus then, we have demonstrated by morbid anatomy the 
complex structure of that portion of the cutaneous tissue 
which is interposed between the corium and epidermis, to 
which Malpighi first called our attention, under the appellation 
of the corpus mucosum vel reticulare ; he likewise observed 
in the coloured layer, that appearance of network, which ar- 
rested my attention both on the blistered surface of the chest 
of the negro, and in the skin of the individual affected with 
elephantiasis, as I have just mentioned. 

From the time of Malpighi to the present day, our knowl- 
edge of the anatomy of the cutaneous tissue cannot be said 
to have made any important advances. The ingenious trea- 
tise recently published by M. Gautier has added some new 
facts to those with which the Italian anatomist was acquaint- 
ed ; and the pathological observation which I have just re- 
corded, appears to me to establish the accuracy of the results 
which he has announced. Accordingly, I think we may now 
consider it beyond all doubt, that the skin of the white man, 



LESIONS OF NUTRITION. 131 

as well as of the negro, and of all animals in general, is com- 
posed of several parts or layers, which in different species 
either attain their maximum of developement, or exist in such 
a rudimentary form, that it is only under the influence of some 
pathological circumstances they acquire such a degree of de- 
velopement as to become discernible. 

Different portions of the fibrous tissue, are likewise not un- 
frequentiy found in a state of hypertrophy, which sometimes 
manifests itself by a simple increase of the natural volume of 
this tissue, and sometimes by its unusual developement in points 
where it generally exists as a rudiment, and can only be de- 
tected by a minute and careful dissection, or even where its 
existence is only inferred from inductions derived from com- 
parative anatomy. 

Of hypertrophy of the cartilaginous tissue we know but 
little ; that of the osseous system is exceedingly common, and 
presents a great number of varieties, of which I shall defer 
the description, until I come to treat of the diseases of the 
organs of locomotion. 

To the second volume, I shall also postpone all observation 
respecting hypertrophy of the nervous tissue ; only remarking 
here, that its existence has been most clearly established in the 
nervous centres (both the brain and the spinal marrow). 

Hypertrophy of the mucous tissue should be considered as 
existing, 1. in the muscles of animal life ; '2. in the fleshy sub- 
stance of the heart ; 3. in the contractile layers which envel- 
ope the mucous membranes of the alimentary canal and blad- 
der ; 4. and lastly, in several other parts, where, under the in- 
fluence of disease, a muscular structure becomes perceptible, 
which, in the healthy condition of the part, is either totally im- 
perceptible, or presents only a rudimentary appearance ; as in 
the trachea, bronchial tubes and gall bladder. Here again I 
must remark, that some of these pathological conditions of the 
muscular tissue in the human subject, are analogous to the 
natural condition of the same part in other animals. 

It occasionally happens, that the minute vessels which con- 
vey the blood through the substance of the various tissues, 
acquire an unusual developement, and present an appearance 



132 LESIONS OF NUTRITION. 

as it were of vegetation : in this state, when clustered together, 
they form tumours of various shapes and dimensions, which 
are sometimes prominent, and somes lie concealed in the 
parenchyma of the tissue or organ where they are formed. 
These vessels may compose the tumour almost exclusively, be- 
ing supported only by cellular tissue ; or they may exist merely 
as accessories in tumours composed of other anatomical ele- 
ments, such as excrescences of the mucous membrane. I 
recollect having once found in the intestine, a soft reddish 
tumour of the size of a walnut, attached to the mucous surface 
by a broad pedicle. This tumour was composed, 1. of the 
mucous membrane scarcely altered from its natural state ; 2. 
of the submucous cellular tissue, which was remarkably thick- 
ened and indurated, and constituted the principal part of the 
bulk of the tumour ; 3. of numerous veins clustered together 
in purple festoons on the free surface of the tumour, so as to 
resemble small hoemorrhoidal tumours distended with blood. 
In this production, which may be ranked among the vegeta- 
tions, or polypi, as they have been termed, I could distinguish 
no other morbid alteration than a hypertrophy of some of the 
natural tissues of the intestine. 

When these vessels are thus increased in size, and therefore 
apparently in number, they sometimes undergo a peculiar mod- 
ification in their texture, which gives rise to the formation of a 
tissue, for which I cannot find a better standard of comparison, 
than the structure of the spleen. In fact, we observe, just as 
in the spleen, numerous areolae filled with blood, communica- 
ting freely with each other, and with large veins, the parietes 
of which, perforated in all directions, are divided at their ter- 
mination, or rather origin, into simple filaments, losing them- 
selves ih the areolar tissue. In these veins and areola?, the 
blood either circulates or stagnates, and in this way its quan- 
tity is exceedingly variable, and thus produces rapid changes 
in the consistence, form, and size of the tumour. In such 
cases, the blood not unfrequently escapes, and thus gives rise 
to copious haemorrhages. 

The blood which is found in the areolae presents the same 
varieties in its appearance, consistence and colour, as the 



LESIONS OP NUTRITION. 133 

blood effused into the cells of the spleen ; thus, in different 
tumours, or parts of the same tumour, it appears colourless, 
pale-red, greyish, like the lees of wine, or as black as the 
pigment of the choroid ; it is perfectly fluid, of the consistence 
of currant jelly, or hard as a piece of muscle ; sometimes it is 
impossible to separate it from the solids which invest it, some- 
times it is easily removed by washing and pressure, the paren- 
chyma in which it was contained then presenting exactly the 
appearance of a spongy texture : in all these respects it per- 
fectly resembles the appearance and structure of the splenic 
parenchyma. 

Such is the morbid alteration which has been described 
under the various appellations of fungus hsematodes, san- 
guineous tumour, and more recently accidental erectile tissue. 
In the midst of this vascular developement, other lesions of 
nutrition or secretion may likewise occur; hence it is that in 
several tumours of fungus haematodes, there have been found, 
in addition to the peculiar anastomosis of vessels constituting 
its basis, different morbid productions, such as fibrous or 
scirrhous masses, pus, melanosis, &c. Similar tumours are, 
not uncommonly, formed in the cutaneous tissue, and more 
frequently still in the subcutaneous and intermuscular cellular 
tissue. They are also found in the mucous membranes and 
their subjacent tissues. Of all the parenchymatous organs, 
the testicle appears most liable to this disease, which con- 
stitutes in it one of the varieties of sarcocele. I recollect 
having seen, in the hospital La Charite, a number of erectile 
tumours developed in the lungs of an individual, who had had 
one of his testicles removed several months before, in con- 
sequence of its being the seat of a tumour that was likewise of 
an erectile nature. The tumours in the lungs, five or six in 
number, were each about the size of a walnut: thev were 
embedded in the substance of the lung, which was perfectly 
healthy all around them; and in the points they occupied, it 
looked exactly as if the parenchyma of the spleen had taken 
the place of the pulmonary structure. In another case, for the 
particulars of which I am indebted to Professor Marjolin, a 
tumour, perfectly resembling a portion of the spleen, was 



134 LESIONS OF NUTRITION. 

found in the brain of an individual, who, like the patient at La 
Charite, had also had one of his testicles removed for the 
same affection, as was ascertained on examining it after the 
operation. 

Hypertrophy, when considered as affecting the different 
organs, should be distinguished into two species; according as 
it affects the entire mass of an organ, or, as it affects only 
some of the anatomical elements which enter into its com- 
position. For instance, the cellular tissue of any organ may 
become so hypertrophied as to form the predominating in- 
gredient in the composition of that particular organ, while at the 
same time, by virtue of a species of balance or compensation 
in the nutritive powers of the part, the other tissues undergo a 
corresponding diminution of volume, and are reduced to a 
state of partial or even perfect atrophy. Sometimes also it 
happens, that when an organ is composed of several tissues 
peculiar to itself, one of them acquires a preternatural devel- 
opement, whilst the others retain their ordinary dimensions, or 
else suffer a diminution of volume. In general, whenever an 
organ is in a state of hypertrophy, its vessels acquire an un- 
usual developement : the same remark has not as yet been 
verified with respect to its nerves. 

The organs which are in a state of hypertrophy may un- 
dergo various modifications in their size, their form, and in 
their apparent structure. Their size may either be increased, 
unaltered, or diminished. Of these three cases, the first is 
decidedly the most common ; the others may, however, occur, 
when, at the same time that one of the tissues of the organ is 
in a state of hypertrophy, the others are reduced to a state of 
atrophy ; or when the hypertrophied organ is hollow, and the 
deposition of the additional molecules is confined to its internal 
surface, in which case, its cavity is either diminished or alto- 
gether obliterated. Sometimes, on the contrary, the hyper- 
trophy of an hollow organ co-exists with a remarkable in- 
crease of its cavity ; whilst, in other cases, it is neither in- 
creased nor diminished. 

When only some of the compound tissues of an organ are 
affected with hypertrophy, the appearance of the part is in 



LESIONS OP NUTRITION. 135 

some cases so completely altered, as to render it almost im- 
possible to recognize it. It may then easily be mistaken for 
an accidental production, or may give rise to the supposition, 
that the original tissue was replaced by a newly-formed tissue, 
when, in reality, the only alteration in its texture or composi- 
tion consisted of an unusual increase of nutrition in one or more 
of its anatomical elements. 

Hypertrophy may exist simple and uncombined, or may co- 
exist with other alterations of the tissue or organ affected. 
Thus it may be combined with hypersemia, or, on the con- 
trary, with anaemia. In the latter case, the part hypertrophied, 
receiving less blood than natural, become,s pale and exsangue- 
ous ; in this state we frequently find portions of cellular tissue 
when affected with hypertrophy. It is true that in such cases 
the hypertrophy may have been preceded by hyperamia ; 
but, during the progress of the affection, the hyperaemia disap- 
peared, and was succeeded by anaemia. Thus it is that we 
sometimes find the parts affected of their natural colour, some- 
times presenting different shades of red or brown, and some- 
times also, colourless and exsangueous. In like manner, their 
consistence is, in some cases,' unaltered ; in others, (and they 
are the most numerous,) increased; and in others, again, dimin- 
ished, the tissue hypertrophied being at the same time in a state 
of softening. 

From the observation of the phenomena of hypertrophy, let 
us now proceed to investigate its causes. The production of 
this morbid alteration has been by many Pathologists attributed 
to an increased afflux of blood towards the organ affected. 
This increased local determination of the nutritive fluid may 
readily be conceived to perform a very important part in the 
production of hypertrophy ; but, in my opinion, it cannot be 
considered as its sole, or even as its essential cause. I do not 
consider it as the sole cause, because the increased determina- 
tion of blood to an organ can, of itself, only produce the con- 
gestion of that organ, but can never cause its hypertrophy, un- 
less when aided by a corresponding increase in the assimilating 
powers of the part. Now, if these powers be supposed in- 
creased, the other condition become unnecessary ; for, the in- 



136 



LESIONS OF NUTRITION. 



creased powers of assimilation, by their more active appropri- 
ation of the nutritive particles contained in the ordinary supply 
of blood, are sufficient to produce the preternatural growth or 
hypertrophy of the part, independently of any increase in the 
quantity of the nutritive fluid. 

But, though I admit in some cases of hypertrophy an in- 
creased energy of the assimilating powers, I am far from con- 
sidering its existence as necessary for the production of every 
species of this affection. Why may not cases occur in which, 
whilst the powers of assimilation remain in their natural con- 
dition, there is a decrease in the powers of disassimilation, or, 
in other words, of that force by virtue of which the molecules 
of the various solids are constantly detached, and absorbed 
into the circulating medium from which they were originally 
derived? Is it in such cases, that hypertrophies that had been 
combated in vain by bloodletting and emolients, have yielded 
to the use of stimulants, such as iodine, mercury, &c? Let us 
turn from these speculations, to the consideration of facts ; 
from which we may derive the following conclusions. 

1. Several hypertrophies are produced simply by an in- 
creased exercise of the functions of the affected organs. 

2. Other hypertrophies have been known to proceed to an 
acute, but more frequently to a chronic, attack of hypersemia. 
In such cases, the hypertrophy is sometimes confined to the 
tissue which was previously in a state of irritation and hyper- 
aemia ; while sometimes, after the tissue originally affected has 
returned to its natural healthy condition, the adjacent tissues 
retain a chronic form of disease, and fall into a state of hyper- 
trophy. Such is frequently the termination of inflammation of 
the skin and mucous membranes. 

3. Lastly, there are certain cases of hypertrophy, in which 
the existence of a healthy or morbid stimulus in the organ af- 
fected, can be inferred only from analogy with the preceding 
cases. To attribute such changes of tissue to nutritive irrita- 
tion of the part, appears to me wholly gratuitous ; why not as 
well attribute them to a diminution of its powers of decompo- 
sition ? Each opinion seems to me equally hypothetical. I 
would therefore recommend, that the treatment of this affec- 



LESIONS OF NUTRITION. 



137 



tion should be founded on neither of these theories exclusive- 
ly, but that the existence of hypertrophy being once ascer- 
tained, we should endeavour to discover experimentally what 
are the most efficient means of combating and subduing it. By 
adopting this method of proceeding, iodine has been discover- 
ed to possess the power of dissipating the hypertrophy of the 
thyroid ; and mercury has been proved a no less powerful 
agent, in destroying certain forms of exostosis, truly resulting 
from hypertrophy of the osseous tissue. 

Those hypertrophies, the cause of which cannot be traced 
to any previous or present irritation of the affected organ, may 
be divided into two classes. In one, they consist of a purely 
local affection ; in the other, they appear intimately connect- 
ed with the condition of the whole system, and may be con- 
sidered as local indications of the thorough alterations which 
the function of nutrition has undergone in every part of that 
system. 

In this class are to be ranked persons affected with scrofula, 
in whom not the least remarkable of the various groups of 
morbid phenomena which they present, is the simultaneous 
hypertrophy of the brain, the thyroid gland, several parts of 
the osseous system, the liver, the tongue, and the upper lip. I 
should have but a very poor opinion of the physiological knowl- 
edge of any one who should consider each of these modifica- 
tions of nutrition as merely a local affection, and, as such, 
should direct his attention to it only, neglecting the really im- 
portant indication of attending to the general state of the con- 
stitution. 



ARTICLE II. 

Atrophy. 

There are several organs in man and other animals, which 
only retain their perfect developement until a certain definite 
Vol. I. 19 



138 LESIONS OF NUTRITION. 

period, after which their vital activity diminishes, and they are 
gradually absorbed. In some organs the period of atrophy 
commences at an early stage of foetal life ; thus, the vesicula 
nmbilicalis speedily disappears, when its functions cease to be 
requisite for the further developement of the embryo. In 
others, the period of decay commences at the termination of 
intra-uterine existence ; at that time, the thymus gland, supra- 
renal capsules, and certain blood-vessels, begin to dissappear, 
and the left lobe of the liver diminishes in size ; and as the in- 
dividual advances in life, each subsequent period of his exist- 
ence is marked by the atrophy of one or more organs. Thus, 
in old age, the lymphatic ganglions are no longer visible ; the 
ovaries are reduced to their fibrous envelope, and can, in some 
cases, with "difficulty be detected amidst the peritoneal folds 
which contain them ; the parenchyma of the lungs is likewise 
rarified to an extraordinary degree: this increased capacity of 
the air cells so constantly observed in old age, is evidently pro- 
duced by the atrophy of the bronchial tissue, and, according 
to its various degrees of developement, presents a striking anal- 
ogy to the pulmonary apparatus in the natural families of the 
chelonea and batrachia. These phenomena of atrophy are 
still more remarkable in certain animals, which in the course 
of their existence undergo various metamorphoses. Thus, in 
the tadpole, when about to change into a frog, the tail gradu- 
ally disappears, and the gills are obliterated, and their place 
supplied by lungs, which lay in a rudimentary state, as long as 
the animal retained the form of a tadpole, and respired only in 
water. 

Atrophy, considered in this point of view, may be regarded 
as a grand physiological phenomenon, which occurs through- 
out the animal kingdom in every organ whose functions be- 
come less exercised, or altogether suspended. In such cir- 
cumstances, the process of atrophy is subject to certain deter- 
minate laws, which regulate its progress, and under similar 
circumstances invariably produce similar results. But there 
are also certain cases, in which atrophy can no longer be 
viewed as a healthy phenomenon, or as regulated by the laws 
of physiology ; on the contrary, it proceeds from an infringe- 



LESIONS OF NUTRITION. 



139 



ment of their laws, gives rise to a variety of functional de- 
rangements, and constitutes a true pathological condition. 
The circumstances which in such cases appear principally to 
favour its developement, are the following : 

1. A diminution in the usual supply of blood. 

2. A diminution of the nervous influence in the part. 

3. A diminution in the activity, or a total suspension of the 
functions of an organ. 

' 4. Imperfect sanguification proceeding from some chronic 
disease of the lungs, or of other organs subservient to the pro- 
cess. In this case, several organs may be simultaneously re- 
duced to a state of atrophy, in consequence of the bad quality 
of the blood which they receive. 

5. Irritation : this cause in general operates indirectly, and 
produces the atrophy of one tissue by attacking an adjoining 
tissue, and increasing the activity of its nutrition ; as the ex- 
cessive vitality of the one produces a proportionate diminution 
in the vital powers of the other, and thus reduces it to a state 
of atrophy.* 

Atrophy produces certain general modifications in the parts 
where it exists. It diminishes their volume, producing in the 
membranes a preternatural thinness of tissue, and in the paren- 
chymatous parts, a diminution of bulk. There are, however, 
cases in which the atrophy of an organ may be very consider- 
able, without producing any perceptible diminution of its vol- 
ume ; such cases can only occur, when the organ affected with 
atrophy becomes at the same time rarified in its texture, as is 
exemplified in the lungs and bones. The consistence of the 
atrophied organ is likewise generally diminished : in some 
cases, the alteration amounts only to an unusual flaccidity of 
tissue ; in others it constitutes a more or less perfect state of 



* I have seen suppuration of the gall bladder followed by perfect atrophy of 
the part. In a middle aged man an abscess formed in the right hypochondri- 
um, and gave exit to several calculi, such as are generally found in the gall 
bladder. The abscess healed in a few months, and the man subsequently died 
of an organic affection of the liver. On dissection no trace of- the gall bladder 
could be found ; its place was occupied by cellular tissue. 



140 LESIONS OF NUTRITION. 

softening. The colour of the part is likewise changed ; most 
commonly it becomes paler than natural. Its internal struc- 
ture, too, is not less altered than its external aspect : the size 
of its arteries diminishes, and, in consequence, its supply of 
blood diminishes also ; the proper texture of the part becomes 
every day less apparent, and it frequently presents only a few- 
traces of its original organization, and sometimes, even none 
at all, the greater proportion, or the whole, of its bulk being 
reduced to cellular tissue, that general element and first step 
of all organization, and that to which it tends to return in pro- 
portion as it becomes more simple. 

At the same time that an organ is reduced to a state of 
atrophy, it very often has an unusual quantity of fat deposited 
around it, which is in general proportional to the diminution 
in the bulk of the organ. The same phenomenon is observed 
in the animal kingdom : in proportion as an organ decreases 
in volume, a fatty secretion is deposited around it ; thus, in the 
spermaceti whale, and many of the fish tribe, an oily substance 
fills the very considerable space which exists between their 
diminutive brain and the parietes of the cranium. 

The thinning of the membranous tissues which results from 
their atrophy, and the gradual disappearance of their mole- 
cules, whether with or without diminution of their consistence, 
may proceed so far as to produce a complete solution of con- 
tinuity in one or more points of those tissues ; so that in this 
manner we may have both ulcerations and perforations formed, 
as a simple result of atrophy, and totally unconnected with, 
and independent of any antecedent inflammation. It is scarce- 
ly necessary to add, that if this doctrine be admitted, the ex- 
istence of these lesions can no longer be considered as unerr- 
ing indications of the pre-existence of inflammatory action. 
Indeed, so far am I from subscribing to the general opinion, 
that every ulceration and perforation must necessarily be pro- 
duced by inflammation alone, that I am disposed to think that, 
in many cases, an attentive and dispassionate consideration of 
the circumstances which attend the developement of these 
lesions, and of the anatomical condition of the parts adjacent, 
would justify the conclusion that they result from a diminution 



LESIONS OF NUTRITION. 141 

of vitality, a deficient supply of the nutritive fluid, in a word, 
from a true state of atrophy, such as naturally takes place in 
the membrana pupillaris, and produces the perforation of the 
iris. Hence it appears, that as the functions of an organ may 
present the same derangements, whether the part be affected 
with hypersemia or anaemia, so likewise, its anatomical struc- 
ture may present the same alterations as consequences of these 
two opposite affections. 



ARTICLE III. 

Ulceration. 

Ulceration is the process by which ulcers are formed on 
the living body. The term ulcer is applied to that solution of 
continuity which is produced in a tissue by the absorption of 
its molecules. With the mechanism of this process we are 
altogether unacquainted ; all that we can appreciate, are the 
different morbid lesions which precede its formation : these 
lesions are as follow. 

1. A state of hypersemia unaccompanied by any alteration 
of nutrition or secretion. This hypersemia is most frequently 
of the sthenic character: sometimes it occupies a considerable 
extent of surface, in different points of which a number of 
ulcers appear scattered up and down ; sometimes the hyperse- 
mia is circumscribed, and presents the appearance of a small 
red patch, which, after remaining stationary for a longer or 
shorter time, at Jength presents in its centre a solution of con- 
tinuity, which extends with greater or less rapidity to its cir- 
cumference, and in this manner an ulcer is formed in the place 
previously occupied by the circumscribed redness. The di- 
mensions of the ulcer may either correspond exactly with those 
of the preceding local hypersemia, or may continue to spread 
indefinitely. 



142 



LESIONS OF NUTRITION. 



But, the formation of an ulcer may also be preceded by a 
true state of passive hyperemia, or even by a simple mechan- 
ical hyperemia ; indeed, one of the commonest species of 
ulcers is that which is found on the legs of old men, and of 
persons of all ages indiscriminately who are employed in 
manufactories, where their occupations oblige them constantly 
to maintain the erect position, at the same time that they are 
exposed to the influence of several debilitating causes ; (a 
crowded damp room, ill ventilated, and from which the solar 
rays are excluded ;) in such cases, the only morbid alteration 
which constantly precedes the ulcerative process, is a stagna- 
tion of the venous blood, or, at least, a considerable retarda- 
tion of its course, as evinced by the brown or violet colour of 
the integuments. I think it highly probable, that the forma- 
tion of such ulcers is owing to the inordinate accumulation of 
blood in the capillary vessels, which produces by its presence 
a local stimulus, such as would result from the presence of a 
foreign body. 

2. Different alterations of nutrition. In fact, there is not 
one of them, which after a variable period, may not become 
the seat of a new morbid action, terminating in the formation 
of an ulcer. Can we conceive any morbid actions apparently 
more dissimilar than that which gives rise to the formation of 
the hypertrophy, the thickening or the induration of a tissue, 
and that which produces its ulceration ? and yet all these mor- 
bid states frequently terminate in ulceration. Several of the 
affections called cancerous are, in fact, nothing more than a 
succession of these morbid conditions in the same part. Many 
of those tumours termed scirrhous, or cancerous, appear to 
consist altogether of masses of hardened cellular tissue, that 
are ulimately transformed into ulcers, which, spreading slowly, 
or rapidly, superficially, or deeply, successfully engage all the 
adjacent tissues. How frequently do we observe a small 
nodule in the skin, evidently caused by the thickening and in- 
duration of the cutaneous tissue, remain stationary for a num- 
ber of years, without undergoing the slightest alteration in its 
size, form, or texture ; but at length, either spontaneously, or 
in consequence of some slight friction, or other irritation, be- 



LESIONS OP NUTRITION. 143 

come the seat of an increased determination of blood, and 
finally be converted into an ulcer, the vast extent and fright- 
ful progress of which bear no proportion whatever to the 
small size of the primitive nodule, or to the stationary condi- 
tion which it maintained for so long a period. The greater 
number of the ulcers which occur in mucous membranes, have 
their commencement in the follicles, some of which were in a 
state of congestion and induration for some time previous to 
their ulceration. 

3. Morbid secretions. Whenever any of these secretions 
are developed in a tissue or organ, there is a constant tenden- 
cy in the part towards the accomplishment of a general law 
of the ceconomy, by virtue of which every foreign body formed 
in a part endowed with life, or introduced there from without, 
must be eliminated and expelled. In order to accomplish this 
object, at a variable period after the formation of the morbid 
secretion, whether pus or tubercle, &c. the living organized 
molecules in contact with this production, undergo a process 
of irritation, which terminates in the absorption of those mole- 
cules ; in this manner is produced a solution of continuity, or 
ulcers, which may either cicatrize, remain stationary, or extend; 
after the removal of the morbid secretion from the system, 
either by the natural outlets, as when pulmonary tubercles are 
evacuated by the bronchia, or by exits accidentally formed, such 
as the different fistulous passages. If the morbid secretion be 
a solid, such as tubercle, the process of ulceration, is preceded 
by suppuration, the product of which, combining with the 
morbid product, gives it the appearance of undergoing a pro- 
cess of softening. In all such cases, the whole process of 
softening consists in the combination of the molecules of the 
newly formed pus with the molecules of the original product, 
whatever it may have been. 

4. Gangrene. Certain portions of the skin, of the mucous 
membranes, and of the parenchymatous parts, especially of 
the pulmonary parenchyma, when affected with gangrene, and 
detached in eschars, leave after them ulcers, which vary con- 
siderably in their disposition to cicatrize. In the lung, this 
produces a cavity, of which the true origin has for a long time 



144 LESIONS OF NUTRITION. 

been altogether mistaken, and which shall be particularly de- 
scribed in the second part of this work. Ulcerations of the 
mucous membranes, arising from the detachment of gangrenous 
eschars, are of much less frequent occurrence than has been 
generally supposed ; the error seems to have originated in 
mistaking for the sloughs of gangrene, detached portions of 
false membranes of a grey colour and foetid smell, which fre- 
quently come away without producing any solution of continu- 
ity in the mucous tunic by which they were exuded ; or else 
the glands of Pleyer in a state of tumefaction and excoriation, 
and tinged of a dirty grey by the contact of faecal matter, or 
changed to black by certain degrees of irritation. 

It is essential to bear in mind, that, whatever be the nature 
of the morbid lesion which precedes the ulcerative process, 
the formation of that process, though connected with a degree 
of irritation, whether acute or chronic, does not depend on it 
as its sole cause ; for, by irritating a tissue in various degrees, 
we cannot produce its ulceration ad libitum : the fact is, that 
the ulcerative process depends on certain special conditions, 
which reside neither in the intensity nor in the duration of the 
irritation by which it is constantly either preceded or accom- 
panied. We often observe an ulcer of frightful dimensions 
succeed to an irritation of short duration, and so slight as to 
be scarcely appreciable ; whilst an irritation of the greatest 
intensity such as is produced in the stomach by the swallowing 
of concentrated acids, or of long duration, such as exists in the 
intestinal mucous membranes of persons affected with chronic 
diarrhoea, shall not produce a single ulcer. It is also of im- 
portance to remark, that in many cases ulceration must not 
be considered as the result of any local affection ; but rather 
as an indication of a general morbid condition, the existence 
of which is revealed by local affections most varied with res- 
pect to their seat and apparent nature. Thus, in scorbutic 
patients, the blood loses its property of coagulating, and 
haemorrhages take place at different points, while at the same 
time numerous ulcers are formed on the cutaneous surface, 
and not unfrequently attack the mucous membrane of the 
mouth also. In like manner, in persons of the scrofulous 



LESIONS OF NUTRITION. 



145 



diathesis, in whom all the phenomena of nutrition and secre- 
tion are so remarkably modified, we frequently observe ulcers 
formed on the skin, the mucous membranes, and even in the 
bones. The abuse of mercury is a not unfrequent source of 
ulcers ; whilst its judicious use promotes the healing of another 
class of these affections. 

Some ulcers have an especial disposition to spread super- 
ficially whilst others, without increasing their superficial diam- 
eter, burrow deeply into the substance of the part. When 
ulcers of this character are situated in the interior of a cavity, 
they successively attack all the tissues which constitute its 
parietes, so that each in its turn constitutes the bottom of the 
ulceration, the external tissue is at length destroyed, a perfora- 
tion follows which may give rise to either of these two cases. 
1. The cavity whose parietes are perforated, is, by this per- 
foration made to communicate with another cavity, either nat- 
ural or accidental. 2. Before the perforation takes place, 
adhesions are formed between the ulcerated organ and those 
organs which are in immediate contact with it : so that when 
the perforation is accomplished, the parietes of the organs with 
which the adhesions were contracted, supply the place of the 
perforated parietes, stop up the bottom of the ulcer, and pre- 
vent the escape of the fluids from their natural cavity. 

The hypersemia which in almost every instance precedes 
the ulcerative process, may either continue after that process 
is established, and give rise to different shades of colour, or 
may disappear altogether, leaving not only the parts around 
the ulcer, but likewise its edges and base, pale and exsangue- 
ous. In such cases, the only appreciable alteration which the 
part presents, is the solution of its continuity. The mucous 
membranes afford frequent examples of the perfectly white 
ulcers, which are often found perforating their surface in nu- 
merous points. 



Vol. I. 20 



146 LESIONS OF NUTRITION. 



CHAPTER III. 

Lesions of Nutrition whicli affect the Consistence of the Ele- 
mentary Particles constituting the different Solids. 

The consistence of the different tissues which enter into 
the composition of our organs is liable to considerable varia- 
tions from the effects of age, sex, and temperament ; similar 
variations may likewise be observed in the different species of 
the animal kingdom. Thus, the cellular tissue of the embryo, 
which is soft, pulpy, and gelatinous, is remarkably different 
from the same tissue in the adult, and still more so, from that 
of the old ; and the dry, firm, brain of the latter presents a 
striking contrast to the infants brain, which is almost totally 
devoid of consistence, and to the perfectly fluid brain which 
belongs to the embryo, during the earlier period of its evolu- 
tion. In like manner, if we follow the cartilaginous and liga- 
mentous tissues through the several periods of their develope- 
ment, we shall find that at their first formation they partake 
more of the nature of fluids than of solids, and subsequently 
pass through the various gradations of consistence, until they 
finally attain that degree of density and hardness, which is 
peculiar to those tissues in their perfect state. In the different 
species of animals, we constantly observe the greatest varie- 
ties of consistence presented by the same tissue, according to 
the species in which it occurs. The same portion of cellular 
tissue which, in one species of animal, is soft and extensible, 
in another, acquires a degree of hardiness almost equal to that 
of cartilage. The sclerotica, which in man is purely ligamen- 
tous, has a tendency to become cartilaginous, or even osseous, 
in birds. The epithelium which lines certain portions of the 
mucous membrane of the alimentary canal, and which in car- 
nivorous animals is so remarkably thin and delicate, acquires 
a much greater degree of consistence in herbivorous animals, 
especially in the horse ; and in birds furnished with a muscu- 
lar stomach, it forms on the internal surface of the gizzard a 



LESIONS OF NUTRITION. 



147 



membrane of considerable strength, rough to the touch, and 
almost as unyielding as cartilage. 

Even in the same animal, the mere change of diet and or- 
dinary habits, may produce various alterations of consistence 
in several of its tissues ; thus, the soft pale flesh of our domestic 
animals, bears scarcely any resemblance to the firm dark 
coloured flesh of the same animals in their wild state. If we 
examine man in all his varieties of temperament, whether 
natural or acquired, we shall find, that he presents a still 
greater variety in the consistence of his skin, and his cellular 
and adipose tissues, as well as of his muscular system in gen- 
eral. Lastly, there are certain cases in which parts of the 
living system undergo a temporary softening, in order to aid 
the accomplishment of some physiological actions ; and re- 
sume their former consistence when that end has been attain- 
ed. Thus, the fibro-cartilage which completes the symphysis 
pubis, undergoes a softening in the females of certain animals 
at the period of each parturition. 

From these facts, we learn, that, in the healthy state, vari- 
ous causes, more or less appreciable, are constantly exerting a 
powerful influence over the consistence of the different solids ; 
several of these causes act likewise on the fluids, producing in 
them, as in the solids, an increase or diminution of cohesion ; 
so that the blood may present the same variations in its con- 
sistence, that we have already seen produced in the muscular 
fibre. Of these variations of consistence, whether of the 
fluids, or solids, some are purely physiological, and are conse- 
quently compatible with perfect health : others, though not 
exactly amounting to disease, can scarcely be considered as 
healthy phenomena ; they are in general connected with some 
peculiarity of temperament, and certain special conditions of 
hBematosis and innervation : and when an individual of such 
a temperament is attacked with disease, there is a certain 
peculiarity in its symptoms, progress, and termination, which 
might have been anticipated from the degree of consistence 
of the skin, muscles, and cellular tissue, possessed by the in- 
dividual. What a difference do we often observe in the char- 
acter of an inflammatory attack of the gastro-intestinal mu- 



148 LESIONS OF NUTRITION. 

cous membrane in two individuals, one of whom has soft 
flabby flesh, whilst the other is quite of a contrary habit of 
body. 

But it is not only as effects of certain physiological laws, or 
as connected with those general conditions of the body, usu- 
sually called constitutions or temperaments, that those varia- 
tions of consistence, of which I have just given some exam- 
ples, are observed in the different solids : they frequently pro- 
ceed from a true morbid condition of the part, and are at- 
tended with more or less derangement in the functions of the 
organ whose consistence is altered. This alteration may 
either consist in an increase of consistenc, constituting indura- 
tion, or in its diminution, which constitutes softening (ramol- 
lissement). If we proceed to investigate the causes of these 
two opposite conditions, we at once arrive at the disputed 
question, whether they both proceed from one and the same 
cause, irritation, or in other words, from an increase in the 
organic action of the part affected. If I could venture to 
solve any theorem in Medicine a priori, I would unhesitating- 
ly reply to the question in the negative ; and in support of my 
opinion, I would repeat the observations I have offered on the 
variety of causes, which in the physiological or healthy state 
are capable of effecting a change in the consistence of the 
different organs, and I would ask, what there is in common 
between the greater number of these causes and irritation, 
and whether several of them do not produce an effect dia- 
metrically opposite to that of irritation. Now, if all these 
cases in which induration is physiologically produced, we ad- 
mit the agency of several cases, each capable of producing 
the same alteration, I should be glad to know why this altera- 
tion, when pathological, may not likewise proceed from more 
causes than one : this question shall be discussed in the two 
following articles. 



LESIONS OF NUTRITION. 149 

ARTICLE I. 

Induration. 

Induration consists in an increase of the natural consis- 
tence of the tissues, without any other alteration of their 
texture. In this state they acquire a greater degree of den- 
sity than natural, and offer a stronger resistance to pressure, 
tearing, or cutting ; when struck they frequently emit a pecu- 
liar sound, and when divided yield a peculiar grating noise 
under the scalpel, which has been erroneously considered 
characteristic of scirrhus. 

Induration may be divided into two species ; according as 
it results from an alteration in the nutrition of the solid parti- 
cles which enter into the composition of the tissues affected, 
or as it proceeds from some change in the quantity or quality 
of the fluids exhaled into their texture. 

The first species may be again subdivided, as follows : 

1. The induration which naturally takes place in certain 
tissues from the progress of age : this species has already been 
alluded to. 

2. The induration which takes place at an early period of 
life, whether occurring in those tissues which have a natural 
tendency to that affection at a later period, (such as certain 
portions of the cellular, muscular, fibrous, cartilaginous, and 
osseous tissues,) or in other parts, which do not usually acquire 
a greater degree of density or hardness in old age. Thus, the 
parietes of the heart are sometimes found so firm and unyield- 
ing, as not to collapse when pressed, and its cavities seem 
distended by some elastic fluid which resists the falling in of 
their parietes. Laennec has remarked that when a heart thus 
indurated is struck, it yields a peculiar sound, similar to that 
elicited by striking a horny substance. This induration of the 
heart's structure may exist either in combination with, or inde- 
pendently of, the hypertrophy of that organ ; as these two al- 
terations are perfectly distinct, and should be carefully dis- 



150 LESIONS OF NUTRITION. 

tinguished from each other, as well in the heart as in other 
organs. The liver, the thyroid gland, the pancreas, the lym- 
phatic ganglions, and the ovaries, likewise not unfrequently 
present a considerable degree of induration of their texture 
unconnected with any other alteration. 

In the second species of induration, the solid portion of the 
tissue, or organ, retains its natural appearance ; and its in- 
creased consistence depends exclusively on a modification of 
the fluids, which may either exist in the blood itself, or in the 
fluids which are separated from it. In acute pneumonia, for 
instance, the blood which accumulates in the parietes of the 
bronchial vesicles, by producing the tumefaction of these pari- 
etes, obliterates the cavity of the air cells, and thus prevents 
the ingress of any elastic fluid : under these circumstances, the 
consistence of the pulmonary parenchyma appears singularly 
increased, but the appearance is altogether deceptive ; for, 
although the lung may have lost its accustomed softness, it has 
at the same time acquired an extreme degree of friability, so 
that the slightest pressure, or attempt at tearing, is sufficient 
to break it up. It is quite otherwise in those cases, where, in 
consequence of a protracted sanguineous congestion, the solid 
texture of the lung has itself acquired an increased degree of 
consistence ; the induration is then real, and the lung thus in- 
durated is with great difficulty torn or divided. The unusual 
hardness which the spleen occasionally presents, is in like 
manner caused by the increased density of the blood which 
fills its areolae. There is a disease peculiar to new-born in- 
fants, generally known by the name of induration of the cellu- 
lar tissue, {skin-bound cirronosis,) which, as in the case of in- 
duration of the spleen, consists altogether in an alteration of 
the qualities of the fluid exhaled into the cells of the tissue, 
which, on dissection, are found distended by a concreted al- 
buminous matter. The blood of individuals thus affected, is 
found to be materially altered in its sensible qualities, its se- 
rum containing, in large quantities, a matter which coagulates 
spontaneously, and forms a gelatinous mass, perfectly identical 
with the matter infiltrated into the areolae of the cellular tis- 
sue — (Chevreul — ) Hence we learn, that in these cases, as in- 



LESIONS OP NUTRITION. 151 

deed in many others, the disease is not confined exclusively 
to the solids, but exists likewise in the blood ; and that the 
morbid secretion which is generated, or at least contained, in 
the blood, is the same which, when effused into the cellular 
structure, constitutes the cause of the disease. Who, I would 
ask, could have ventured to anticipate such a curious patholog- 
ical fact some few years back, when it was the reigning 
fashion of the day to attribute all cases of hardening of the 
cellular tissue, either to an organic affection of the lungs or 
heart, or to an acute or chronic inflammation of the alimen- 
tary canal ? And who will now take upon himself to deny, 
that in certain tumours called scirrhous, composed as they are 
of cellular tissue, having its areolae filled with concreted albu- 
minous matter, there may not, as in the general induration of 
the same tissue in new-born infants, be a concomitant altera- 
tion of the blood ? May not the blood furnish this scirrhous 
deposit which makes its appearance simultaneously in different 
and often remote parts of the body ; which has a remarkable 
tendency to be reproduced in those parts from which it has 
once been removed ; and which, in many cases, is preceded 
by no appreciable alteration in the structure of the part affec- 
ted ? No doubt, this supposition is purely hypothetical ; but, 
if it accounts satisfactorily for several circumstances connec- 
ted with the production of scirrhous tumours, which are other- 
wise inexplicable, and if it be (as I consider it) derived from a 
fair and legitimate analogy, it at least deserves to be ranked 
among those hypotheses which merit a careful and dispassion- 
ate examination. 

In some cases, the two species of induration already des- 
cribed occur conjointly, and may be observed passing one 
into the other. When, for instance, we examine the cellular 
tissue which surrounds old indolent ulcers, we observe several 
morbid alterations, which are evidently different degrees of 
one and the same lesion ; thus, the cellular tissue in the im- 
mediate vicinity of the ulcer, is considerably harder than nat- 
ural, and presents the appearance of a solid homogeneous 
mass, of a dead white colour, resembling the fat of bacon ; at 
a little greater distance, the consistence diminishes, and is no 



152 LESIONS OF NUTRITION. 

longer uniform ; and the lardaceous appearance exists only in 
some isolated points, the interval between which is filled by a 
soft, yellowish, inelastic tissue, which on pressure exudes a 
semiconcrete, gelatinous fluid ; at a still greater distance from 
the ulcer, the same fluid exists, but gradually diminishes in 
consistence, until at length it becomes a simple serosity, infil- 
trating a pale, extensible, cellular tissue, resembling that which 
is found in a part affected merely with oedema. 

Parts in a state of induration present great varieties in their 
appearance ; the principal of which depends on the colour, 
size, and form of the part, and likewise on the absence or pres- 
ence of other species of organic alterations. 

The indurated tissue seldom retains its natural colour. 
Sometimes it is remarkably pale and colourless, either in 
consequence of actually receiving less blood than usual, or 
from the presence of the concreted albuminous matter, which 
is one of the most constant causes of induration of the cellular 
tissue ; sometimes, this indurated part, instead of being pale, 
presents an unusual colour ; thus, in some cases it is red, in 
others greyish, yellow, brown, or even black as ebony. These 
different colours evidently depend either on the various de- 
grees of stagnation of the blood in the indurated part, or on 
the exhalation of different colouring matters into it. We fre- 
quently find such deposits of colouring matter, in infants af- 
fected with the disease already mentioned (cirronosis), in 
whom the concreted serosity, which produces the sub-cutane- 
ous induration, is generally tinged by two colouring principles, 
the one of an orange red, the other of a bluish shade ; and 
(what is extremely remarkable) these colouring principles, as 
well as the concreted serum, are likewise found in the blood, 
as has been ascertained by M. Chevreul. 

Hence induration may be distinguished, with regard to the 
different shades of colour it presents, into, 1. induration with 
evident colourless state of the parts (white induration) ; and, 
2. induration with unusual coloration (grey, yellow, or black 
with many intermediate shades). The white or grey indura- 
tion constitutes those tumours which authors have denomina- 
ted scirrhous. The black induration has erroneously been 



LESIONS OF NUTRITION. 153 

considered as forming a peculiar accidental tissue, designated 
by the name of melanosis. I shall return presently to the con- 
sideration of these words, and of the true meaning which 
ought, in my opinion, to be assigned to them. 

The volume of indurated parts is no less variable than their 
colour. In some cases, the size is neither increased nor di- 
minished ; in others, and they are the most numerous class of 
cases, it is increased ; and, lastly, the indurated organ some- 
times undergoes a real diminution in its size. This latter con- 
dition may depend on various circumstances. 1. In certain 
parenchymatous organs, some of the anatomical elements of 
which they are composed may fall into a state of atrophy, or 
even disappear altogether, at the same time that those which 
remain acquire a remarkable degree of hardness : such is of- 
ten the condition of the liver, one of the tissues of which in- 
creases in size and becomes indurated, whilst the other shrinks, 
and has a tendency to be even totally absorbed. The ovaries, 
too, present a similar alteration of structure, for their fibrous 
tissue often acquires a remarkable degree of hardness, at the 
same time that their parenchymatous structure is reduced to 
a mass of cellular tissue with a few vessels traversing its sub- 
stance. 2. When the induration of an organ depends on the 
condensation of the fluids which enter into its composition, the 
volume of the part may undergo a remarkable diminution ; as 
is exemplified in those cases of indurated spleens, which are 
at the same time much smaller than natural. 3. When the 
quantity of the fluid part of an organ diminishes, in proportion 
as the solid part acquires a greater degree of consistence. As 
an instance of the diminution of volume of an indurated organ 
proceeding from this cause, I shall describe a case which once 
presented itself to my notice, in which the spleen had under- 
gone a remarkable diminution of size, being scarcely as large 
as a walnut, and was composed almost exclusively of a fibrous 
envelope, which was thick and extremely hard. In its interior 
was found a cavity divided into several compartments by fi- 
brous bands ; these compartments contained only a small quan- 
tity of reddish serum, altogether different from the usual con- 
tents of the splenic cells ; the splenic artery was ossified, and 
Vol. I. 21 



154 LESIONS OF NUTRITION. 

its calibre so diminished, that a fine probe could with difficulty 
be introduced ; the vein, immediately after emerging from the 
spleen, resumed its usual dimensions, and presented nothing 
remarkable in its structure. 

The modifications of form to which a part in the state of 
induration is liable, are the same as have already been de- 
scribed as occurring in cases of hypertrophy or atrophy ; it is 
therefore unnecessary to repeat them here. 

The induration of an organ is invariably a slow process, un- 
less in those cases where it depends on a change in the prop- 
erties or in the consistence of the fluids of the part ; in which 
case it may take place in a very short space of time. Thus, 
in living animals when laid open, and their respiration and 
circulation consequently greatly disturbed, we often see the 
spleen suddenly acquire a remarkable degree of firmness, ac- 
companied in some cases with an increase, in others, with a 
diminution, of its volume. 

What are the causes which produce the induration of a tis- 
sue or organ 1 To this question we can only reply by stating 
the results of observation on the subject. 

In many cases the appearance of induration has been for a 
long time preceded by all the signs of active hyperemia ; this 
occurs, especially, in portions of the cellular tissue, in the mu- 
cous membranes, and in the pulmonary parenchyma. It is, 
however, of some importance to recollect, that, although a pro- 
cess of irritation may have preceded and produced the indura- 
ted state of the part, it by no means follows, that this irritation 
should persist after the induration is once formed ; on the con- 
trary, the vitality of the part, and the quantity of blood which 
it receives, are in many cases, considerably less than before 
the consistence of the part was augmented ; so much so in- 
deed, that, in an organ partially indurated, the parts whose 
consistence is increased not unfrequently resemble inert mas- 
ses of foreign matter deposited in the substance of the organ. 

These facts are important, inasmuch as they explain how it 
is, that, in a great number of cases, certain tissues in a state of 
induration, have been restored to their original condition by 
producing in the man artificial hyperasmia, either by the appli- 



LESIONS OF NUTRITION. 155 

cation of topical irritants, or by introducing into the stomach 
certain substances capable of restoring the equilibrium of the 
nervous influence, and of invigorating the capillary circulation. 
Are we to conclude, that, because in many cases induration 
of a tissue is preceded by an increase in its organic action, it 
necessarily must be so in every case? For the solution of this 
question also, let us have recourse to observation and facts, 
and from them we shall learn, that not a few cases have been 
observed, in which, during life, not a single symptom indicated 
any determination of blood to the part, either previous to, or 
during its induration, and in which, after death, no trace could 
be discovered of any such determination having existed ; so 
that, in all such cases, it is from analogy alone that active hy- 
persemia can be admitted as the cause of the induration. But 
I would ask, is the knowledge which we possess of the laws 
which regulate the nutrition of the several tissues sufficient to 
justify us in assuming, that no tissue can change its consistence 
without having first been in a state of irritation, or in other 
words, unless the laws which preside over its composition and 
decomposition have taken on them a preternatural activity? In 
the present state of our knowledge, all that we can positively 
affirm is, that the induration of a tissue is often preceded or 
accompanied by an increased action in the part ; but we have 
no authority to lay it down as an established principle, that 
this increased action, or irritation, is the sole and indispensable 
cause of every increase of consistence in the organic mole- 
cules. If we confine ourselves to the observation of facts, we 
must be content to say that irritation is one of the most con- 
stant elements in the production of induration ; but if we as- 
sert that it is the most important and indispensable element in 
its production, we state that which has not as yet been proved, 
unless by a very questionable analogy. Whatever degree of 
importance we attach to the agency of irritation, as contrib- 
uting to produce this alteration of nutrition, it .must on all hands 
be admitted, that, taken singly, it is totally inadequate to ex- 
plain its phenomena ; for, in almost every alteration of struc- 
ture, we may detect the presence of irritation, and yet, we 
never can trace the specific differences of these alterations to 



156 LESIONS OF NUTRITION. 

any corresponding differences either in the degree or in the 
duration of the accompanying stimulus. If we attempt to ex- 
plain it by saying, that there is a difference in the nature or 
mode of the irritation, we only offer a conjectural explanation 
of the fact, which may be accounted for just as plausibly by 
the hypothesis that, in many cases, where a tissue or organ is 
in a state of induration, there is a diminution in the activity of 
the absorbents, an unusual stagnation of the fluids in the are- 
olae of its cellular tissue, and, as a necessary consequence, con- 
densation and increased consistence of its organic molecules ; 
or, that, in certain cases of induration, the venous circulation 
of the indurated part is retarded, and that consequently there 
is a deposit of serum, which accumulates and concretes in the 
cellular tissue; doubtless these opinions are purely conjectural, 
but, like the hypothesis of irritation, they hav£ some analogies 
in their support, and will be equally acceptable to any unpre- 
judiced mind. In my opinion, we know no more of the essen- 
tial primary cause which determines the induration of a tissue, 
than we do of the cause which produces any other alteration 
of nutrition. All that we know about the matter is, that this 
cause frequently produces its effects in parts which have pre- 
viously been in a state of irritation ; but there is no proof what- 
ever that irritation must invariably precede this alteration of 
nutrition. Few persons, I presume, will feel inclined to main- 
tain, that a bone which is so overcharged with phosphate of 
lime as to become dense as ivory, must necessarily have been 
previously in a state of irritation or inflammation ; and yet, if 
the intermediate stage of irritation be not essentially necessary 
in this case, why should it be so in similar alterations of the 
cellular tissue or mucous membrane ? If the views which I 
have offered on this subject be correct, they deserve the seri- 
ous meditation of the practitioner ; for they are by no means 
indifferent in a practical point of view. In order to restore 
an indurated part to its natural condition, the practitioner will 
not rest satisfied with stimulating or soothing the part, but 
will search empirically in the Materia Medica for such sub- 
stances as, when absorbed into the general circulation, and 
brought into contact with the elementary ingredients of the 



LESIONS OF NUTRITION. 157 

solids and fluids, may modify or destroy the unknown cause, 
under the influence of which the induration of the part was 
produced. 

To recapitulate, induration, considered with respect to its 
connexion with irritation, presents the following varieties : 

1. Irritation may be the first phenomenon apparent ; evi- 
dently preceding the induration, and continuing after its forma- 
tion. 

2. Irritation having, as in the preceding case, existed at the 
first stage of the affection, may subsequently disappear ; so 
that the indurated tissue may continue in that condition, 
though unaccompanied by any irritation whatever. 

3. In many cases, there is no evidence of the induration 
of a tissue having been at any period preceded by irritation. 

4. Whether irritation has existed or not during the first 
stage of the affection, a period may arrive, when the quantity 
of blood sent to the indurated tissue is actually less than before 
its induration, and when its vitality is also less than in the 
natural state of the part. 

5. In an indurated tissue, two species of irritation may exist, 
which it is important to distinguish. The one may be called 
the primary irritation, as it precedes, and occasionally contrib- 
utes to produce the induration of the part ; the other may be 
termed secondary, at it comes on at a longer or shorter period 
after the formation of the induration. This secondary irrita- 
tion is sometimes the means of restoring the indurated part 
to its healthy condition ; but more frequently it is productive 
of the most injurious consequences to the indurated organ, 
which, under its influence, acquires a remarkable disposition 
to ulcerate, and become the seat of various morbid secretions, 
while this alteration in the disposition of the part is generally 
attended with serious constitutional symptoms. This is what 
constitutes the transformation of scirrhus into cancer, in the 
language of the old school of pathologists, or in the language 
of Bayle, and his school, the passage of scirrhus from the state 
of crudity, to the state of softening. 

From the preceding parts we may deduce several useful 
therapeutic indications, both for the prevention and cure of 



158 LESIONS OF NUTRITION. 

induration. They enable us readily to understand, how op- 
posite modes of treatment may succeed in removing this 
morbid alteration of nutrition, according to the condition of 
the part affected, which, as we have already seen, is subject 
to considerable variety. In some cases, for example, the prin- 
cipal, indeed the only indication, consists in removing the 
sanguineous congestion, or in preventing its recurrence ; and 
consequently the antiphlogistic treatment is the only one 
which should then be had recourse to. But if, on the contra- 
ry, we have reason to suppose that the indurated organ re- 
ceives less blood, and enjoys a minor degree of vitality than 
in its healthy state, a different method of treatment must then 
be adopted ; it is under such circumstances that the topical 
application and internal exhibition of stimulants may be ration- 
ally employed. This precept is far from being theoretical ; 
it is, in fact, only the rational exposition of a system of treat- 
ment which has long since been sanctioned by experience, 
and which though liable to be abused, has in many instances 
been attended with the most decided success. It is scarcely 
necessary to add, that this practice requires the greatest cir- 
cumspection on the part of the practitioner, who should always 
bear in mind, that though he may, by the stimulating plan of 
treatment, in some cases, restore an indurated tissue to its 
natural conditions, he may also, by the same method, increase 
the primary irritation if it subsists, or produce the secondary 
irritation, the fatal effects of which have been already alluded 
to. In addition to these two methods of treatment, which, 
though, opposite, are nevertheless equally rational, a third 
method, although empirical, may be conceived as adapted to 
the treatment of induration ; the object of which will be to 
endeavour, by experiment and observation, to discover wheth- 
er there exist any substances which, when taken into the cir- 
culation, possess the faculty of so modifying the process of 
nutrition, as to restore to the molecules of the indurated tissues 
their natural consistence. I will not take upon me positively 
to affirm, that such substances do exist ; but the physician 
who has seen the effects of mercury in dissipating exostosis, 



LESIONS OF NUTRITION. 159 

and promoting the cicatrization of ulcers, will not treat the 
suggestion as puerile and absurd. 

It is the more important to ascertain precisely what methods 
are best adapted to the treatment of induration, as in several 
cases in which the indurated tissue was situated externally, 
the parts affected have been seen to re-assume their natural 
consistence. This has particularly been observed in portions 
of the cellular tissue affected with that species of induration, 
which has been long known by the appellation of lardaceous. 
They have been observed to lose successively their great 
consistence, and to present, instead of a homogeneous solid, 
a dense areolar tissue infiltrated with a white or yellow se- 
rum ; subsequently the areolar tissue becomes more delicate 
and extensible ; the serous effusion, too, diminishes in quantity, 
and, finally, the' part re-assumes all the qualities of cellular 
tissue in its healthy state. In some cases, the part undergoes 
a different process ; the induration having, as in the preceding 
case, diasappeared, the cellular tissue which had been affected 
falls into a state of atrophy, so that the part which, when in- 
durated, exceeded its natural dimensions, subsequently expe- 
riences a considerable diminution of volume, in consequence 
of the deficiency of the cellular and adipose tissues. In other 
cases, lastly, the diminution of volume which succeeds to the 
state of tumefaction and induration, does not depend so much 
on the atrophy of the cellular tissue, as on the state of the 
muscles, which having been compressed and atrophied by the 
mass of indurated cellular tissue, do not resume their natural 
condition, when that pressure has been removed by the return 
of the tissue to its healthy state. If the cellular tissue which 
surrounds old ulcers situated on the surface of the body, can 
thus recover from its state of lardaceous induration, and re- 
sume its healthy structure, or pass into a state of atrophy 
(which may be looked upon as another method of cure), may 
not the same sanative process take place in portions of the 
cellular tissue more internally situated ; for instance, in that 
portion which lines the mucous membrane of the stomach, 
the induration of which constitutes the greater number of the 
so called scirrhous tumours of that organ? In both cases, 



160 LESIONS OF NUTRITION. 

there is a perfect analogy of structure and organization, as 
well as disease ; why then should there not likewise exist 
an analogy in their sanative processes ? 



ARTICLE II. 

Softening. 

The softening of the different tissues, or, in other words, the 
diminution of their cohesion, was only vaguely described by the 
older anatomists, but has particularly engaged the attention of 
modern observers ; and so successful have been the recent in- 
vestigations on this subject, that there is scarcely an organ in 
the body, in which this remarkable alteration of nutrition has 
not been detected. As I shall have occasion in the second 
part of this work to describe the softening of each organ indi- 
vidually, I shall at present offer only a few general remarks on 
the effects of this diminution of cohesion on the different ele- 
mentary tissues. 

The cellular tissue is often affected with softening ; in which 
case the tissues which it serves to unite, lose their natural mu- 
tual cohesion, and may be separated from each other with the 
greatest facility. Thus, it is very easy to separate large por- 
tions of mucous or serous membrane from the subjacent parts, 
when the cellular tissue which connects them to these parts 
has lost its ordinary consistence. As, in some cases, the cellu- 
lar tissue of an organ is the only one affected with this lesion, 
so, in other cases, it is the only tissue which remains intact, all 
the others having entirely lost their natural consistence. Hence 
it is, that in certain cases of softening of the brain and spinal 
marrow, the cellular tissue alone remains behind, having sur- 
vived the destruction of the nervous matter which was con- 
tained in its areolae : indeed it is only in such cases that the 
existence of cellular tissue in the brain is well capable of de- 
monstration. 



LESIONS OF NUTRITION. 161 

The serous tissue also frequently loses its natural consistence, 
and may then be reduced to a soft pulpy mass by the slightest 
friction. Such a diminution of cohesion often exists in this 
tissue without any other appreciable alteration, and, conse- 
quently, without any evidence of having been preceded in its 
formation by any increased determination of blood ; more fre- 
quently, however, it is accompanied by the exhalation of va- 
rious fluids either on the free surface of the tissue, or on that 
by which it is attached to the adjacent ones. 

The mucous tissue is peculiarly liable to all the varieties of 
softening ; in some cases presenting only a slight diminution of 
consistence, in others, being transformed into a soft pulpy sub- 
stance, or even into a fluid destitute of any trace or organiza- 
tion. Sometimes the affection engages the whole substance 
of the mucous membrane ; sometimes it is confined to one of 
its component parts. For example, in those portions of the 
mucous membrane which are furnished with an epithelium, the 
softening may be exclusively confined to that delicate layer, 
which may then be detached in shreds almost totally devoid of 
consistence, so as to have the appearance of molecules. When 
the mucous membrane is provided with villi, the affection may 
be confined to these, without at all engaging the subjacent 
membranes, in which case the villi are reduced to a mere de- 
tritus, or disappear altogether, leaving in the place which they 
occupied a superficial ulceration or erosion, which does not at 
all affect the continuity of the true mucous membrane. 

The cutaneous tissue also frequently undergoes different 
degrees of softening ; and in it, as in the mucous membrane 
this affection may attack the component layers individually, or 
may engage them all at once. For example, certain cutane- 
ous diseases consist of such an alteration in the secretion of 
the epidermis, as to reduce that layer, which ought to form a 
solid stratum over the rete mucosum of Malpighi, to the con- 
sistence of a liquid which affords little or no protection to the 
denuded cutis. In many cases it is possible to trace the seve- 
ral stages through which the epidermis passes from the solid 
to the fluid state ; or vice versa, when it returns to its natural 
degree of consistence. It may not be unimportant to observe, 
Vol. I. 22 



1652 LESIONS OF NUTRITION. 

that this alteration in the nutrition of the epidermis which 
produces its liquefaction, is very often combined with the so 
called scrofulous diathesis ; so that we have here another ex- 
ample of the connexion which subsists between a local altera- 
tion of nutrition, and the general state of the constitution ; 
and I again repeat, that the only rational mode of combating 
the local affection, is by attempting to modify that state of the 
constitution on which it depends. The dermoid tissue, prop- 
erly so called, may lose its consistence in various ways. 1. 
When mechanically distended by fluids accumulated in its 
subjacent cellular tissue, it becomes remarkably soft, and is 
sometimes reduced to a delicate soft pellicle, which tears with 
the slightest effort. 2. In certain individuals it gradually loses 
its fibrous texture, assimilates itself to the cellular tissue with 
which it is in contact, becomes confounded with it, and eventu- 
ally acquires its soft friable consistence. 3. This tissue fre- 
quently softens down, becomes reduced to a pulpy consistence, 
and is totally destroyed, by the effects of different degrees of 
active sanguineous congestion. As the skin, so likewise its 
different horny productions, in man and other animals, are 
subject to such a degree of softening as to reduce their natu- 
ral firm texture to a soft cheesy consistence. They may even 
be secreted in the liquid form, and afterwards continue so ; 
and it is remarkable, that in this case, as in the softening of 
the epidermis, already alluded to, this diminution of consis- 
tence, when affecting the nails, in the human subject, frequent- 
ly co-exists with other alterations of nutrition which charac- 
terize the scrofulous diathesis ; so that whether our object be 
to investigate the nature, or to stop the progress of this soft- 
ening of the nails, or of the other morbid alterations by which 
it is accompanied, we shall in vain hope for success if we 
confine our attention solely to the part affected. 

The vascular tissue may, like those already enumerated, 
lose its natural consistence. The softening to which this altera- 
tion gives rise, may frequently be observed in the coats of the 
arteries and veins, and is generally confined to their internal 
tunic, where it appears occasionally to precede the ulcerative 
process. In some cases, however, all the coats of these ves- 



LESIONS OF NUTRITION 



163 



sels are softened together ; and many years have now elapsed 
since M. Dupuytren announced, that the facility with which a 
ligature applied to an inflamed artery divided its coats, was 
owing to the softening of its cellular tissue. The fibrous coat 
is sometimes transformed by softening, into a pulpy, inelastic 
substance, which is easily torn by pressure, or even reduced 
to a pultaceous mass. Isolated points in this condition have 
been observed in the coats of the blood-vessels, and to such 
an origin must be attributed many of the perforations which 
occur both in the arteries and veins. 

The cartilaginous tissue may lose its natural cohesion, so as 
to present three different appearnces. 1. It loses its elasticity, 
and in some points is reduced to a sort of paste, which yields 
under the finger, and is easily broken down by the slightest 
pressure. 2. The dry and elastic cartilaginous tissue of the 
adult, in some cases reassumes the appearance and qualities 
which it presented during infancy ; that is to say, the aqueous 
ingredients preponderate in its composition, and while it loses 
its elasticity, it acquires some degree of extensibility ; in short, 
it seems to pass from the state of cartilage, to that of fibro- 
cartilage. 3. The cartilaginous tissue of the adult may pre- 
sent all the sensible qualities which characterize its appear- 
ance during the earlier periods of the evolution of the foetus ; 
that is to say, in consequence of the great portion of water 
which it contains, it becomes soft, mucous, and transparent as 
jelly or glue. 

The fibrous tissue presents nearly the same varieties and 
degrees in its softening as the cartilaginous tissue. 

The softening of the osseous system has long attracted the 
attention of anatomists. We have frequent examples of this 
affection in the disease called rickets, which consists in such a 
want of due firmness in the bones, in consequence of a defici- 
ency of the phosphate of lime in their structure, that they 
may be bent or twisted in any direction by the efforts of their 
own muscles, or any external force if applied for a sufficient 
length of time. In some diseases of the bones, they offer no 
resistance to the knife, and may be cut like lard. In other 
cases, the compact structure of the bones is so altered, that 



164 LESIONS OF NUTRITION. 

their interior presents throughout an areolated texture filled 
with a thin fluid, and limited externally by a delicate pellicle 
of bone, which is so remarkably brittle that it may be either 
cut or broken by the slightest effort. 

The tissue of the muscles of animal life loses its consist- 
ence in the following cases. 1. In the greater number of 
those cases where the surrounding cellular tissue is infiltrated 
with pus, as is observed in the vicinity of large abscesses. 
2. It also becomes affected, but only so far as to lose its natu- 
ral firmness, during the course of chronic diseases, or in con- 
sequence of having been long unexercised : under these cir- 
cumstances the muscles likewise lose their natural colour. De 
Haen relates a remarkable case of softening of the muscles of 
an individual who was seized with paralysis of the upper ex- 
tremities, after an attack of painter's colic : the muscles of 
the paralyzed extremities, though still retaining a slight degree 
of contractility, were reduced to the consistence of a soft, 
pulpy mass ; the paralysis subsequently disappeared, and the 
muscles of the arms at the same time regained their usual 
consistence and firmness. Barthez has recorded the case of 
another individual, who, under similar circumstances, was af- 
fected with a similar softening of both deltoid muscles: in 
this case, too, the affection disappeared with the paralysis. It 
is a remarkable circumstance, that this flaccid state of the 
muscular system frequently co-exists with a diminution in the 
natural cohesion of the molecules of the blood. It is an old 
observation, though I am not prepared to say how far it is 
true, that, after certain kinds of death, such as those caused 
by electricity, the poison of the viper, and some narcotic 
vegetables, the muscles become soft more rapidly and more 
completely than when death occurs from other causes. 

The muscles of organic life have likewise been observed in 
a state of softening : for example, in almost all the muscular 
expansions which surround the mucous membrane, a remark- 
able diminution of cohesion has been met with. The soften- 
ing of the heart is sometimes so complete, that the slightest 
pressure from the finger is sufficient to pierce its parietes 



LESIONS OF NUTRITION. 165 

through and through, and the least effort, to tear them in any 
direction. 

The softening of the nervous tissue was accurately described 
many years ago by Morgagni, but has ' recently been much 
more fully investigated : indeed it is to the successful investi- 
gations of this species of softening, by M. M. Lallemand and 
Rostan, that we are indebted for the reseaches which have 
since been made by various anatomists respecting the same 
alteration in other tissues. 

Lastly, in almost all the parenchymatous organs, as the 
lungs, liver, spleen, kidneys, uterus, and ovaries, different de- 
grees of diminution of consistence have been observed, which 
shall be described at length when we come to treat specially 
of these organs in the second part of this work. The soften- 
ing of these parenchymatous organs may depend, 1. on the 
diminution of the consistence of their own proper tissue ; 2. 
on the diminution of the consistence of the cellular tissue in- 
terposed between their proper tissue, and dividing it into lob- 
ules, grains, &c. ; 3. on the presence of a certain quantity of 
fluid in the areolae of this tissue, which necessarily tends to 
separate and disunite its molecules ; 4. on an unusual fluidity 
of the blood : the softening of the spleen often depends on this 
cause, and in many cases proceeds so far, that the spleen re- 
sembles in its interior a sort of reddish pulp, and even conveys 
a sense of obscure fluctuation when gently pressed on its sur- 
face, before being opened. But this softening does not proper- 
ly belong to the texture of the spleen ; it depends altogether 
on the unusually fluid state of the blood effused into its cells ; 
as may easily be proved by directing a stream of water on 
such a spleen, and at the same time employing gentle pressure, 
by which process the blood may be all washed away, and the 
areolar tissue of the spleen will remain behind without any 
trace of morbid alteration. 

Softening, considered generally in the different tissues or 
organs which are liable to be affected by it, presents three de- 
grees which it is important to distinguish. In the first, the tis- 
sue retains its solid consistence, but may be ruptured, torn, or 
perforated, with the greatest facility. In the second, the nat- 



166 LESIONS OF NUTRITION. 

ural texture of the part is converted into a pulpy mass, which 
almost approaches to a state of fluidity ; and, in the third de- 
gree, the pulp itself is partially removed, and no trace of the 
original structure remains except in detritus. This last degree 
of softening may frequently be observed on the internal sur- 
face of those cavities which are lined by a mucous membrane, 
of which the debris alone in many cases remain behind, leav- 
ing the subjacent cellular tissue naked and exposed. In this 
manner are formed several of the perforations of hollow or- 
gans, the softening successively attacking and destroying all 
the tissues of their parietes. 

Beside these differences of degree which softening presents, 
we must also admit several species of this alteration, depend- 
ing on the conditions of the tissue or organ affected. These 
species are the more important to determine, as they imply 
not only a difference of appearance, but, in many cases, a dif- 
ference in the nature and character of this affection. The fol- 
lowing species of softening may be established with reference 
to the different shades cf colour which the softened tissues 
present. 

1. Softening in which the natural colour of the part is pre- 
served. The mucous and serous membranes, the tissue sui 
generis of the transparent cornea, the brain, heart, liver, uterus, 
&c. present frequent examples of this species. 

2. Softening attended with blanching of the tissues affected. 
In this case, the part affected is remarkably pale, exhibits a 
milky white appearance, and presents no trace whatever of 
vascular injection. This species of softening has been observed 
both in the membranous and parenchymatous organs; the pale 
appearance by which it is characterized, sometimes arises from 
a diminution in the quantity of blood circulating in the part ; 
in other cases it depends principally on the preternatural infil- 
tration of serum into the cells of the softened tissue. Some 
authors have maintained, that in those cases of softening of the 
brain, in which the softened nervous pulp, so far from being 
congested, is remarkably pale and exsangueous, this alteration 
is caused by infiltration of pus into the substance of the brain : 
this appears to me a mere gratuitous assumption of a fact, for 



LESIONS OF NUTRITION. 167 

the purpose of accommodating all cases of softening to some 
favourite theory. 

3. Softening accompanied with redness. This species is 
particularly common ; so much so indeed, that, in by far the 
greater proportion of cases, the organ affected with diminution 
of consistence presents on dissection unequivocal marks of a 
greater or less degree of hypersemia. In such cases, the blood 
may either remain in its vessels, or make its escape from them, 
and thus constitute effusions, more or less extensive, in differ- 
ent parts of the softened tissues. The cause of such haemor- 
rhages is sometimes wholly mechanical ; as when they result 
from the perforation or destruction of the blood-vessels, by the 
constantly increasing softening of their parietes. Parts affect- 
ed with softening may present various shades of colour, from 
a bright to a dark red, or to a black, grey, or yellow tinge. All 
these different shades depend either on the difference of quan- 
tity of the blood circulating in the part ; on the retardation or 
stagnation of its course ; or, finally, on the production or se- 
cretion of some colouring principle. The redness of the sof- 
tening tissues may be either partial or general ; and in either 
case may present considerable variety of degree, from the 
slight blush produced by a few injected vessels ramifying on a 
white surface, to the uniform dark colour observable when the 
softened tissue is reduced to a red pultaceous mass. 

Parts in a state of softening, when considered with reference 
to their bulk, may present the following varieties. 1. They 
may retain their natural dimensions. 2. Their size may be 
increased, either by a true hypertrophy of the part, or, as is 
more frequently the case, by the simple congestion of its fluids. 
3. They may present a remarkable diminution of volume, be- 
ing in a true state of atrophy. Some facts would lead us to 
suppose, that in a softened part, hypersemia, attended with in- 
crease of bulk from sanguineous congestion, may precede that 
quite opposite state in which there is both anaemia and dimi- 
nution of bulk. 

As to the time requisite v for the production of the various 
degress of softening, no general principle can be established ; 
for there are some cases in which a few days, or even hours, 



168 LESIONS OF NUTRITION. 

are sufficient for the alteration of a tissue from its natural con- 
sistence to that of a soft pulp, or even of a liquid mass (and 
this acute form of softening may either co-exist with an in- 
creased determination of blood to the part, or may exist with- 
out the slightest trace of sanguineous congestion, the part af- 
fected retaining its natural colour). In other cases, again, the 
formation and progress of this morbid alteration are remark- 
ably slow ; so that, in fact, softening is, in some cases, an acute, 
in others a chronic affection, differing in this respect from in- 
duration, which almost invariably exists in the chronic form. 

Can a tissue that has once lost its natural consistence, again 
recover it ? We are not as yet in possession of a sufficient 
number of well authenticated facts to resolve this question. 

As to the causes of this affection, we cannot, it is true, dis- 
cover the proximate cause (which is necessarily uniform) on 
which it immediately depends ; but we can ascertain the phe- 
nomena which usually precede its appearance, and may con- 
sequently be supposed to contribute in some degree towards 
its production. No one of these phenomena can, however, be 
considered as the only efficient cause; for, they may exist in 
every possible variety and degree, without necessarily produ- 
cing the least change in the consistence of the part. Hence it 
appears, that softening, like every other alteration of nutrition, 
is the product of some one peculiar proximate cause, which is 
in all cases uniform and identical ; and on certain occasional 
causes, which are not, like the former, constantly and necessa- 
rily identical, but are merely the series of phenomena which 
generally precede or accompany its formation. Of these phe- 
nomena, there is one which is so much more constant and 
striking than the rest, that it has naturally been considered as 
the cause of most of the forms of the affection ; I mean active 
hypersemia. That this phenomena generally precedes the for- 
mation of softening, and not unfrequently accompanies its prog- 
ress, may easily be established as follows. 1. By examining 
the morbid alterations of structure which generally accompany 
softening, and which are universally acknowledged as the ef- 
fects of active hypersemia. 2. By investigating the causes 
which usually determine the softening of a tissue or organ, and 



LESIONS OF NUTRITION. 



169 



which will generally be found of a peculiarly stimulating na- 
ture. 3. By examining the symptoms to which softening gives 
rise, and which are in most cases similar to those resulting from 
active hyperemia. 4. By considering the treatment adapted 
to this alteration of nutrition, which will be found the same as 
that employed in cases of hypersemia. 

In many cases, the close connexion which subsists between 
active hyperemia as the cause, and softening as its effect, is 
too palpable to admit of dispute. But there are also cases, 
and these not a few, in which no such connexion can be dis- 
covered ; and in which the alterations of structure that accom- 
pany this affection, so far from favouring the idea of the exis- 
tence of inflammation, seem to^indicate a diametrically opposite 
condition of the parts. Of this nature are those cases of soft- 
ening attended with blanching, or with atrophy, of the affected 
organ. It also frequently happens, that the production of 
softening cannot be traced to the action of any appreciable 
stimulus, but that the state of the general system which pre- 
ceded its formation is evidently dependant on some important 
modifications in the function of nutrition all over the body. 
These modifications may either proceed from external causes, 
such as a deficiency in the quantity or quality of air, food, &c. ; 
or from internal causes, such as all derangements affecting the 
organs concerned in the important process of haematosis. 
The symptoms, too, are often widely different from those which 
characterize the increased action or irritation of the organ. 
What resemblance can we trace either in their symptoms or 
effects between the different degrees of inflammation of the 
bones, and the softening of the osseous tissue in rachitis ? Or 
where shall we find the symptoms of encephalitis, carditis, hep- 
atitis, nephritis, metritis, &c. in various cases of softening of 
the brain (especially of its white central portion) and of the 
heart, liver, kidneys, uterus, &c. ; every one of which may 
pass into such a state of softening, that its tissue may be torn or 
broken down into a pultaceous mass, without having given rise 
to a single symptom which could lead to a suspicion of the 
existence of inflammation. 
Vol. I. 23 



170 LESIONS OF NUTRITION. 

Organs affected with softening may be divided into two 
classes, according as their functions are, or are not, deranged 
by this morbid alteration. When there is no derangement of 
function, the affection often remains perfectly latent, and nei- 
ther reveals its existence by any change of sensibility, any 
disturbance of the circulation, any morbid sympathy, nor, in 
short, by any of those symptoms which usually accompany 
every case of irritation, or, in other words, every exaltation of 
the organic action of the tissue or organ. It is under such 
circumstances that softening appears most evidently uncon- 
nected with, and independent of, all inflammatory action. 
When, on the other hand, it produces derangement of the 
functions of the organ affected, as is generally the case when 
the brain or stomach is the seat of the disease, a variety of 
morbid sympathies are called into action, and the symptoms 
of softening become identical, or nearly so, with those which 
accompany every acute or chronic irritation of the part. We 
must not, however, forget, that identically the same functional 
derangements may result from very different organic affec- 
tions ; and that, consequently, derangements of function alone 
cannot serve as an unerring guide to the precise nature of the 
morbid alteration or condition of the affected organ. 

As regards the mode of treatment best adapted to this affec- 
tion, little satisfactory information can as yet be afforded ; as 
it is still a desideratum in the science to have a series of well- 
directed experiments, in which shall be fairly compared the 
different methods by which it has been most successfully 
treated, according to the seat of the disease, the other morbid 
alterations with which it was accompanied, and the nature of 
the symptoms to which it gave rise. Will any man, in the 
present state of our knowledge, take upon himself to maintain 
or deny, that one and the same treatment should be adopted 
both in the cases where softening is combined with hypersemia, 
and in those where no trace of any such combination can be 
detected, whether from the hypersemia having never existed, 
or from its having ceased to exist at an early period of the dis- 
ease? or will any one assert the propriety of combating, by 
means of a purely antiphlogistic treatment, the softening of 



LESIONS OF NUTRITION. 171 

the bones in rachitis, that of the cartilages, nails, and epider- 
mis, in certain scrofulous individuals, and the diminution of 
consistence which is often so conspicuous in several of the tis- 
sues of scorbutic patients ? 

To sum up the results of this discussion, I conceive that, in 
the present state of science, we have no grounds for supposing 
that softening is in every case the necessary result of irrita- 
tion ; but that, on the contrary, the circumstances which fre- 
quently attend its formation, are utterly incompatible with the 
existence of any inflammatory action, either antecedently or 
at the time. Besides, this exaltation in the natural action of 
the part, is in no case sufficient of itself to explain the produc- 
tion of softening. In fact, all the influence it can possibly 
have is limited to producing a deviation from the natural type 
in the nutritive process of the irritated tissue ; it deranges the 
nutrition of the part, but it possesses no control whatever over 
the mode of this derangement, and, if possible, still less over 
its ulterior results. Irritation gives the impulse to the aberra- 
tion of nutrition, but does not produce it ; for the nature of 
this aberration can never be calculated from the intensity, nor 
yet from the duration of the preceding irritation. In theory, 
we have no reason to suppose that softening is necessarily 
preceded by an increased local determination of blood arising 
from irritation, any more than induration or any other altera- 
tion of nutrition ; and in point of fact, we ought not to admit 
a necessary connexion between these two orders of phenom- 
ena, since in many cases we find one of them existing singly, 
without the slightest proof of having been preceded or accom- 
panied by the other. If, however, 1 were disposed to offer a 
theory of my own, I might suggest, that all the varieties of 
softening that occur in sickly, cachectic infants, whose sum of 
vitality is actually below the natural standard ; in old decrepid 
persons ; in adults affected with scrofula, rachitis, or scurvy ; 
and in persons of all ages who are exhausted by chronic dis- 
ease, or food not sufficiently nutritive, as in those animals ex- 
perimented on by M. Magendie, in whom softening of the 
cornea was seen to follow the protracted abstinence from 
proper diet; I say, that all the varieties of softening which 



172 



LESIONS OF NUTRITION. 



occur in these and such like cases, may be considered as 
merely a more advanced degree of the diminution of consis- 
tence, which, in such cases, is observable in the muscular fibre, 
and even in the blood itself. The integrant particles of the 
several tissues are brought together and retained in union, by 
a force of aggregation which is purely and solely vital : if, then, 
(as really happens in an infinity of cases,) the blood and the 
nerves do not support a sufficient degree of vitality in these 
tissues, we can readily conceive, that a diminution in the cohe- 
sion of their constituent particles may result from such a modi- 
fication in the influence of these two grand vital agents ; and 
that thence may arise all the various stages and degrees of soft- 
ening, from the delicate skin, and flabby flesh, of scrofulous 
individuals, to that extreme degree in which the solids lose 
every character of organization, and are reduced to the con- 
sistence of a fluid. 

The softening of several tissues has been attributed to the 
action exercised on them during life by their own acid secre- 
tions. This supposition is, however, by no means established ; 
the facts which have been adduced in its support shall be ex- 
amined when we come to treat of the diseases of the digestive 
apparatus. It has likewise been attempted to establish a 
connexion between certain forms of softening, especially those 
of the stomach, and certain injuries of the cerebral system. 
A German physician states, for instance, that he observed a 
remarkable softening of the mucous membrane of the stomach 
in all the rabbits he had killed by a blow on the nape of the 
neck. I have repeated the experiment without obtaining any 
such result. 

There are certain forms of softening occasionally found in 
the dead body, which seem to have been formed after death, 
and have been attributed to the following causes. 

1. The simple diminution of cohesion which every tissue 
in the body has a tendency to undergo, at a longer or shorter 
period after death. This softening is best marked in the ner- 
vous tissue, where it may be easily detected some time before 
the decomposition of the rest of the body commences. There 
are other tissues, again, which do not present any traces of 



LESIONS OP NUTRITION. 173 

softening until the process of putrefaction is considerably ad- 
vanced. Of this number is the mucous tissue, the softening 
of which seldom commences until a late period, though it is 
considerably accelerated by exposure to the atmosphere, and 
an elevated temperature. 

2. The infiltration or soaking of a tissue by some fluid 
which thus subjects it to a species of maceration. The fluid 
may either be effused into the cavity of an organ, infiltrate the 
areolae of its cellular texture, or lastly, may accumulate to 
excess in the vessels of the part. 

3. The corrosive action exercised on the tissues after death, 
by the juices of their own secretion. This hypothesis, by 
which Morgagni long since explained the formation of certain 
kinds of softening of the brain, has again been revived, in order 
to explain some similar affections of the stomach ; and I shall 
revert to it when treating of the morbid anatomy of this organ. 



CHAPTER IV. 

Lesions of Nutrition, with respect to the Nature of the Mole- 
cules composing the different Solids. 

We have seen the different modifications of nutrition, which 
have occupied our attention in the preceding chapters, pro- 
ducing various alterations in the form, size, consistence, and 
continuity of the parts affected ; but we are now about to 
enter on the consideration of another class, in which the nu- 
trition of a tissue is so modified as to change its nature, and 
convert it into a totally new tissue. 

The transformation of one tissue into another, is one of the 
most universal facts which the study of organized beings re- 
veals. It is one of the striking phenomena presented to us 
in the developement of the embryo, inasmuch as several of 
its tissues do not attain their perfect state, until they have 



174 LESIONS OP NUTRITION. 

successively passed through the intermediate stages of one or 
two other tissues. This process of transformation may, in 
like manner, be observed in the animal series, where, accord- 
ing to the wants of each species, some particular tissue disap- 
pears, in order to be replaced by another. Thus, for exam- 
ple, in different animals, the white fibrous tissue, the yel- 
low fibrous tissue, and the muscular tissue, constantly sup- 
ply the place of each other.* We also find this law of trans- 
formation exemplified in the same animal, especially in man, 
either as a physiological fact occurring at different periods 
of his extra-uterine existence, or, as a pathological fact re- 
sulting from several of the diseases to which he is subject. 

All tissues are not equally liable to transformation, nor does 
this process take place in the same manner in them all. Their 
morbid transformations are subject to a certain number of 
laws, which may be enumerated as follows. 

A. All the natural tissues may be produced at the expense 
of the cellular tissue, which appears to be, by some morbid 
process, actually transformed into each of them, or at least to 
resign its place to them ; so that it is in the same cellular tex- 
ture which constitutes the original framework or matrix in 
which, during the evolution of the embryo, all the other tis- 
sues were originally deposited, that in the adult all these tissues 
may be again accidentally developed. 

B. The nervous tissue cannot be thus formed at the expense 
of the cellular tissue, unless in those points where it had pre- 



* The longitudinal muscular coat of the large intestine in the human sub- 
ject is, in the horse, replaced by a fibrous coat. The parietes of the inferior 
vena cava, which in man are of a simple cellulo-fibrous structure, acquire in 
several of the larger mammalia a fleshy muscular appearance, especially near 
the heart. The suspensory ligaments of the horse's sheath are fibrous ; those 
of the bull are muscular. The middle coat of the arteries is fibrous in man, 
and likewise in the horse ; but in the elephant is muscular, according to Cuvier. 
The superficial fascia of the abdomen in man is composed of the white fibrous 
tissue ; and in the horse, of the yellow ; while in didelphous animals, this 
expansion changes not only its form and dimensions, but likewise its texture, 
and is transformed into a muscular envelope, which surrounds the abdominal 
pouch peculiar to these animals. 



LESIONS OF NUTRITION. 175 

viously existed naturally. Beclard has seen divided nerves 
re-connected in this way. All the other tissues may be pro- 
duced indifferently in any part of the cellular texture. 

C. At the same time that the cellular tissue which invests 
the different organs, or enters into their interior, is thus meta- 
morphosed into some other tissue, the proper texture of the 
organ does not itself undergo any transformation, but in some 
cases it remains perfectly unaltered, and in others is reduced 
to a state of atrophy. 

D. The nature of the transformations which the cellular 
tissue undergoes, is in certain cases determined by the nature 
of the functions which it is accidentally called on to fulfil : thus, 
where it is subjected to an unusual degree of friction, it is 
converted into a serous membrane ; where there is an acci- 
dental necessity for the exertion of elasticity, it is changed 
into cartilage ; where parts endowed with life require to be 
protected against the contact of a foreign body, it becomes a 
tegumentary tissue, more or less perfect ; where the head of 
a bone is accidentally displaced, it is transformed into a va- 
riety of tissues, so arranged as to constitute an articulating 
cavity, which, both in its form and structure, bears some 
analogy to the natural joint, &c* 

E. When a tissue has undergone a solution of continuity, 
the cellular tissue, by which it is repaired, is sometimes trans- 
formed into a tissue precisely analogous to the divided one, 
and sometimes into another, by which the divided tissue is 
often replaced in different animals. Thus muscles, when di- 
vided, are often re-united by fibrous tissue, which in different 
animals takes the place of the muscular tissue. In the same 



* These alterations of nutrition, determined by changes of function, may 
likewise be observed in the vegetable kingdom, in which not only a single 
tissue, but an entire organ, is occasionally metamorphosed ; thus, a branch 
when planted in the earth, is transformed into a root, &c. In this kingdom, 
also, another metamorphosis is accomplished by the sole influence of unusually 
abundant nourishment ; namely, the stamina become converted into petals. 
In the animal kingdom, the same cause materially influences the production of 
the different sexes ; for by varying the proportions of their food, we can create 
at pleasure young bees of the male, the female, or of the neuter sex. 



176 LESIONS OF NUTRITION. 

way, a cartilaginous substance is sometimes interposed be- 
tween the fragments of a fractured bone, or an osseous ring 
maintains in contact the two pieces of a broken cartilage ; 
while in the animal series we constantly see these two tissues 
replaced one by the other. 

F. The only tissues, besides the cellular, which are suscep- 
tible of transformation, are such as constantly present similar 
metamorphoses, during the evolution of the foetus, or in some 
parts of the animal series ; such are, the muscular, the fibrous, 
the cartilaginous, the mucous, and the cutaneous tissues. 

G. The accidental transformations which these tissues are 
liable to undergo, are similar to the natural transformations 
which they exhibit in the human embryo, or during the extra- 
uterine existence of other animals. Thus, cartilage may be 
converted into bone, but can never become mucous mem- 
brane. The mucous tissue may be transformed into the cu- 
taneous, and vice versa ; the muscular may be changed into 
the fibrous tissue, but cannot be transformed into any other. 
Thus, we see that the metamorphoses to which these tissues 
are liable are much more restricted than those of the cellular 
tissue. 

H. Those tissues which do not undergo any transformation 
in the human embryo, or in the animal series, in no case pres- 
ent any accidental transformation as the effect of disease ; and 
in those cases where such transformations may be supposed to 
exist, it will be found, on close investigation, that they have 
taken place in the surrounding cellular tissue, or that the al- 
teration consists of an unusual developement of parts which 
generally exist in a rudimentary state ; as where, in man, the 
skin is covered with horny excrescences. 

I. Every tissue, when reduced to a state of atrophy, has a 
tendency to undergo a transformation to its original state of 
cellular tissue ; so that this tissue, which originally preceded 
in its existence the developement of all the other organic ele- 
ments, is again reduced to its original isolated state when these 
other elements are removed. It is curious to observe in the 
animal kingdom, certain tissues thus resolving themselves into 
cellular texture, as they cease to be of use. Thus, the poste- 



LESIONS OF NUTRITION. 177 

rior cervical ligament, which is strongly developed in the 
horse, and still more strongly in the ox, becomes less elastic 
in the sheep, the dog, and the pig ; exists only as a rudiment 
in the cat ; and in man is reduced to mere cellular tissue. But 
even in the human subject, traces of this ligament have been 
observed by anatomists, in the dissection of individuals who 
were in the habit of exerting powerfully the muscles situated 
on the back of the neck, or whose heads, from being constant- 
ly weighed downwards and forwards by heavy loads, required 
to be supported by a ligament similar to that which in animals 
fulfils the same office. 

What is the proximate cause of the transformation of one 
tissue into another ? Is it in all cases to be considered as the 
product of irritation apparent or latent ? It is true that, in 
many cases, the first phenomenon which presents itself to our 
notice in the part where the transformation is subsequently to 
take place, is a degree of excitement attended with more or 
less sanguineous congestion ; but in other cases, again, no 
symptoms of any such antecedent irritation can be observed. 
Indeed, its existence cannot always be fairly admitted, either 
from analogy or induction ; and in this particular modification 
of nutrition, still more than in any other, the preceding irrita- 
tion and sanguineous congestion can only be regarded as giv- 
ing rise to some derangement in the process of nutrition, but 
are altogether inadequate to account for the peculiar character 
of the alteration which ensues. The more we reflect on the 
causes which produce the transformation of one tissue into 
another, the more evident will it appear, that this alteration 
should be considered as the result of an aberration from the 
natural nutrition of the part, preceded in many cases by irri- 
tation, but neither constantly, nor necessarily so. We are, I 
conceive, entitled to say, that the peculiar alteration of nutri- 
tion on which transformation immediately depends, is neither 
necessarily nor constantly preceded by irritation or increased 
local action, since in a very large proportion of cases, we have 
no evidence whatever of its existence, either from the symp- 
toms presented during life or the appearances found on dissec- 
tion ; and since the knowledge which we now possess of the 

Vol. I. 24 



178 LESIONS OF NUTRITION. 

laws of embryogony, as well as of those which regulate the 
nutrition of different animals, enables us to conceive how ev- 
ery species of transformation of tissue may occur independent- 
ly of any antecedent irritation. Is it in consequence of this 
cause that in the fcetus a variety takes place in the origin of 
an artery 1 If then such a change in the situation where the 
nutritive materials are deposited during the formation of the 
fcetus, can be conceived to occur without the aid of any pre- 
ceding irritation, why should the presence of this irritation be 
considered so indispensably requisite at a subsequent period, 
for the production of every change which occurs in the selec- 
tion of these nutritive materials ? Is it in consequence of an 
increased degree of nutritive action in the costal cartilages, 
that those parts are, in old age, transformed into bone 1 that 
the sclerotica of birds is externally osseous, or that, what in 
one animal is muscle, is in another converted into fibrous tis- 
sue, and vice versa ? Are we to suppose that the process of 
nutrition is more active in osseous than in cartilaginous fishes, 
and that the difference of structure which they present, de- 
pends solely on this cause ? In all these cases, the only fact 
which we can really appreciate, is, that one series of nutritive 
particles is deposited in place of another : our knowledge ex- 
tends no farther. We observe a difference in the mode of 
nutrition of the parts, but a difference of mode by no means 
necessarily implies a difference of degree. Let us irritate a 
tissue or organ as we please, produce a determination of blood 
towards it, or excite it by every possible variety of stimulus ; 
we shall nevertheless fail of producing any transformation of 
its tissue, except under circumstances which agree with the 
laws laid down, unless by mere accident ; and even in those 
few cases, in which we do accidentally succeed, no connexion 
whatever can be traced between the effect produced and the 
intensity, or duration, of the preceding irritation. 

Wherever the transformation of one tissue into another 
takes place, the newly formed tissue is in a greater or less de- 
gree analogous to the same tissue as it naturally exists in other 
parts of the body. In the following articles I shall proceed to 
consider the history of each of these accidental tissues sepa- 
rately. 



LESIONS OF NUTRITION. 179 

ARTICLE I. 

Of the Cellular Transformation. 

As I have already had occasion to allude to this species of 
transformation, I shall at present offer only a few remarks on 
it. When treating of atrophy, I laid it down as a general 
principle, that whenever an organ disappeared, a greater or 
less quantity of cellular tissue is found in its place ; such cases 
cannot, however, strictly speaking, be considered as instances 
of transformation ; for the cellular tissue had always existed, 
and was only rendered more apparent by the absorption of 
the proper tissue of the organ. 

Whenever the functions of an organ are totally suspended, 
or even rendered less active than usual, it invariably acquires 
a tendency to lose its natural organization, and to return to 
the state of cellular tissue. Thus we find this tissue, at dif- 
ferent periods of life, occupying the place of the thymus and 
mammary glands, of the ovaries, and of the lymphatic gang- 
lions, «fec. The extremities of an obliterated artery, and of a 
divided nerve, or tendon, lose their distinguishing anatomical 
characters, and are converted into cellular tissue. In the place 
of certain muscles which have for a length of time been totally 
unemployed, it is by no means uncommon to find only a few 
reddish fibres, dispersed through a mass of cellular tissue, from 
which they can with difficulty be distinguished. 

When any part of the body has been affected with active 
hypersemia, it is liable to undergo such an alteration in its nu- 
trition, as shall produce a rapid absorption of its nutritive par- 
ticles, without a corresponding deposition of any new materi- 
als ; in consequence of which the part affected may suffer a 
notable diminution of size, or even disappear altogether, leav- 
ing only cellular tissue in its place. I recollect a remarkable 
instance of transformation of this kind occurring in the gall 
bladder, as a consequence of inflammation of that viscus, at- 
tended with suppuration. In a middle aged man, an abscess 



180 LESIONS OF NUTRITION. 

formed under the cartilaginous margin of the ribs at the right 
side, just over the situation generally occupied by the gall 
bladder : the abscess burst, several biliary calculi were dis- 
charged, and the man subsequently recovered. Several 
months after, another disease, with which he was attacked, 
proved fatal. On opening the body, we sought in vain to 
find any traces of the gall bladder ; in the site which it usual- 
ly occupies we found only a mass of condensed cellular tissue ; 
from the ductus choledochus, we traced a duct which, from its 
situation and direction, must have been the cystic ; but it was 
impossible to follow it farther than the distance of a few lines, 
when it terminated in a cul-de-sac, and was lost in the sur- 
rounding cellular tissue. 

I shall not at present treat of the transformation of various 
organs into fat, or adipose matter, as admitted and described 
by several authors ; because I do not conceive such cases to 
arise from the conversion of one tissue into another, but from 
a preternatural secretion of fat, accompanied with a greater 
or less degree of atrophy of the proper tissue of the organ. 
They will therefore come, with more propriety, under consid- 
eration in the third section of this work, in which I propose to 
treat of the different alterations of secretion. In the same 
place, also, I shall speak of the genuine accidental cellular tis- 
sue, which, under certain circumstances, is really and com- 
pletely formed in the midst of fluids arising from morbid se- 
cretions, and possessing the property of becoming organized. 



ARTICLE II. 

Of the Serous Transformation. 

The serous and cellular tissues present many points of 
analogy in their organization, and functions, as well as in the 
fluids which they secrete, and the diseases to which they are 



LESIONS OP NUTRITION. 181 

liable. We need not, therefore, feel much surprise at seeing 
one of these tissues frequently transformed into the other. In 
the first place, it is, as Meckel has remarked, by no means un- 
common to find cellular tissue substituted for certain portions 
of the serous tissue, even in the healthy state. Thus, where a 
synovial bursa is found in one individual, in another there is 
only found cellular tissue, lubricated with a fluid more abun- 
dant and unctuous than the usual secretion of that tissue. The 
converse of this proposition is equally true ; for in many 
points where, in general, only cellular tissue exists, a serous 
cavity more or less perfect is occasionally found. It is some- 
times impossible to assign any satisfactory cause for this con- 
version of structure ; but, in general, this accidental formation 
of serous tissue may be referred to one of the laws laid 
down at the commencement of this chapter, which states, 
that when the functions of any portion of the cellular tissue 
are accidentally rendered identical with those of the serous 
tissue, the structure of the former tissue is likewise identified 
with the structure of the latter. Thus, when a considerable 
degree^ of friction is for a long time exercised between two 
parts, the cellular tissue which intervenes between them is 
converted into serous tissue. In several of the bird tribe, for 
example, no trace of synovial membrane can be discovered, 
whilst they are still young, between the tarsal bones and the 
tendons which pass over them, these parts being merely sep- 
arated by simple cellular tissue ; but, at a subsequent period, 
as the tendons are more frequently put in motion, a well 
formed serous tissue is found interposed between them and 
the subjacent bones. When the skin has been for a long pe- 
riod subjected to an unusual degree of friction, the cellular 
tissue which separates it from the subjacent parts becomes 
converted into a synovial bursa of greater or less size. Be- 
clard ascertained the existence of a bursa in some club-feet, 
at the point where the skin rubs against the prominent side of 
the tarsus. When the stump of an amputated limb is ex- 
amined at a long interval after the operation, a serous sack is 
not unfrequently found interposed between the skin and the 
end of the stump. Brodie records an instance of a serous 



182 LESIONS OP NUTRITION. 

cavity having been formed between the gibbous protuberance 
of a hump-backed person, and that portion of the skin which 
constantly glided over it. In some cases of unreduced dis- 
location, the bones in their new situation are separated from 
each other by an accidental serous membrane, produced at 
the expense of the intervening cellular tissue : the same thing 
is observed to take place between the extremities of fractured 
bones which do not re-unite. I have myself ascertained the 
existence of a serous sac, filled with an unctuous and appa- 
rently gelatinous fluid, interposed between the extremities of 
one of the cartilages of the ribs, which had been formerly 
fractured.* In all these cases are we to suppose that the cel- 
lular, is converted into serous tissue, solely because it has been 
subjected to an unusual degree of compression, or friction ? 
Such an explanation is, in my opinion, insufficient to account 
for many of the facts of this description with which we are 
acquainted ; and I think we should approach nearer the truth 
in regarding the mechanical cause as only secondary, and in 
considering such transformations of tissue as the accomplish- 
ment of a general law of organization, by virtue of which a 
modification of structure necessarily follows a modification of 
function. When foreign bodies are lodged in the cellular tis- 
sue which surrounds the different organs, or enters into their 
structure, it is often possible to follow the different stages 
through which this tissue passes in its metamorphosis into a 
serous membrane investing the foreign body, and isolating 
it from the surrounding parts. A membrane of this descrip- 



* The formation of serous membranes, in cases of unreduced luxations and 
non-united fractures, which some authors have thought proper to deny, has 
been lately placed beyond all doubt by the investigations of M. M. Cruveilhier, 
Breschet, and Villerme. Eighty-five clays after the formation of a false articu- 
lation in a boy, whose leg had been fractured, these two latter anatomists found 
the surface of the false joint lined by a smooth polished membrane, which had 
all the characters of synovial membrane ; and even so long since as the time of 
Bichat, that immortal anatomist observed in two men who had false articula- 
tions, a genuine cyst, smooth on its internal surface, and lubricated with a serous 
fluid, formed at the expense of the cellular tissue, and constituting, in the words of 
this accurate observer, an accidental synovial membrane. 



LESIONS OF NUTRITION. 183 

tion may frequently be detected in the process of formation 
around effusions of blood. When the clot of blood is thus 
surrounded by an accidental membrane, it is sometimes grad- 
ually absorbed, so that, after a certain time, there is found a 
limpid fluid contained in a true serous cyst, in the place of a 
coagulum of blood surrounded by cellular tissue more or less 
condensed. 

When an organ has suffered a loss of substance, which has 
been but imperfectly repaired, or when a cavity has been 
formed in its interior, and subsequently evinces a disposition 
to contract and become obliterated, a serous cavity is estab- 
lished wherever the divided tissue is incapable of being suffi- 
ciently approximated to close up the cavity. Examples of 
serous membranes thus formed may be found in the brains of 
persons who had at some preceding period manifested all the 
symptoms of cerebral apoplexy ; and in the lungs of individ- 
uals who, at some period long prior to their death, had ex- 
hibited all the symptoms and stethoscopic signs of a tubercular 
excavation. 

In all these cases, the serous sac is formed in the place of 
the portion of the organ which had been destroyed ; but in 
other cases, where there has been no destruction of parts, but 
where these parts have never been developed, a serous cavity 
is likewise found occupying their place. This etiology of their 
formation is quite evident in certain serous cysts which are 
found in the brain ; and is also highly probable in many of 
of those cavities with serous parietes which are occasionally 
found in the substance of the liver, the kidneys, uterus, &c. 

Lastly, serous tissue may be accidentally developed in every 
portion of the cellular tissue, either where it invests the differ- 
ent organs, or enters into their parenchymatous structure ; in- 
dependently of any of these circumstances which we have 
enumerated. The parenchymatous organs are sometimes to- 
tally transformed into a vast serous sac : in such cases it is (I 
conceive) difficult, if not impossible, to decide, whether the 
morbid action which substituted this serous sac for the organ 
whose place it occupies, be an excess of nutritive action (irri- 
tation) ; a diminution of that action, whether primitive or ad- 



184 LESIONS OF NUTRITION. 

ventitious ; or, simply, its perversion. All that can be posi- 
tively affirmed on the subject, is, that in many of this descrip- 
tion it is impossible to seize on any direct proof of an ante- 
cedent irritation. 

In whatever part of the body this serous tissue is developed, 
it invariably assumes the form of a shut sac, and thus con- 
stitutes one of those varieties of accidental cavities or sacs 
which have long been designated by anatomists under the 
name of cysts. This term, as its etymology implies, signifies 
simply an accidental cavity. 

The most remarkable differences may be observed in the 
structure of the parietes of those cavities, the nature of the 
fluids which they contain, and in the origin of their formation. 
With reference to their origin, they may be divided into two 
classes, according as they proceed from some modification in 
the size and structure of a sac which had always existed, (e. g. 
cysts formed by excessive developement of the cutaneous fol- 
licles, the muciparous crypts, or the vesicles of the ovaria,) or 
as they are produced by the morbid formation of some acci- 
dental tissue. In the latter case, nothing can be more variable 
than their organization ; they may be divided into as many 
different species as there are tissues entering into the composi- 
tion of their parietes. At present we shall confine our atten- 
tion to serous cysts, or, at least, to those in which the serous 
tissue is the principal component part of their parites. The 
size of these cysts varies from that of a grain of millet seed to 
the dimensions of an infant's head, or even of that of an adult. 
They may either exist singly, or in groups ; their external sur- 
face is in immediate contact with the tissue of the organ in 
which they are developed : in some cases it is impossible to 
discover any organized connexion between the cyst and the 
tissue ; in others, the cyst is continuous with cellular tissue 
analogous to that which lines the pleura or peritoneum. It is 
often difficult to ascertain precisely where the accidental se- 
rous membrane commences, and the cellular texture termi- 
nates ; for, as the latter becomes gradually more condensed, it 
passes insensibly into the former. In general no red vessels 
can be traced in the parietes of cysts ; but in some few cases 



LESIONS OF NUTRITION. 185 

I have seen several reddish lines traced in an aborescent form 
on their external surface, just as they are observed in some 
cases of hyperaemia of the natural serous membranes. The 
tissues which immediately surround the cyst are by no means 
uniform in the appearances which they present. 1. They may 
retain their natural condition ; or, having lost it for a time, may 
again assume it. This is one of the most common cases. 2. 
They occasionally suffer a considerable degree of shrinking 
and condensation, which may materially affect the due per- 
formance of their respective functions. In this way, I have 
found the tissue of a lung in which a serous cyst was devel- 
oped, entirely deprived of air, although in other respects sound 
in its texture. 3. They are reduced to a state of atrophy. 
This occurs more especially in certain parenchymatous organs, 
such as the brain, liver, kidneys, and lungs, which are some- 
times reduced to a thin layer expanded over the surface of a 
vast serous cyst, which occupies their place. 4. They present 
a remarkable degree of sanguineous congestion, without any 
other apparent alteration. 5. They undergo various altera- 
tions of nutrition, especially induration and softening. 6. A 
morbid secretion is sometimes formed and deposited between 
the external surface of the cyst and the surrounding tissues 
with which it is in contact. In this way, I have frequently 
found serous cysts floating loosely in the midst of large collec- 
tions of pus, of masses of tubercular matter, or of extensive 
effusions of blood ; sometimes these cysts were perfect and 
entire, in other cases they were broken up, and presented only 
the remains of their original structure. I do not mean to af- 
firm that cysts detached from, and unconnected with, any 
solid part, may not be formed in the fluid in which they float ; 
but this case, to which I shall hereafter revert, is essentially 
different from that which we are at present considering. 7. 
Lastly, the cellular tissue investing the cyst is liable to differ- 
ent kinds of transformation. It may become fibrous, car- 
tilaginous, osseous, or calcareous. In this way additional layers 
are formed, which are super-imposed on the accidental se- 
rous membrane, and thus add materially to the thickness of 
the parietes of the cyst. In some cases, these layers afford a 
Vol. I. 25 



186 LESIONS OF NUTRITION. 

complete envelope to the cyst ; in others, they exist only in a 
rudimentary state, as when we observe a few detached fibrous 
bands, or patches of bone or cartilage distributed here and 
there on the external surface of a cyst. 

The internal surface of serous cysts is in general as smooth 
and polished as that of the natural serous membranes. Occa- 
sionally, however, it presents other appearances, which are 
analogous to those presented by the natural membranes as the 
effects of disease. Thus, their internal surface is sometimes 
found rugose, uneven, and studded with opaque granular 
bodies, which appear to me to consist simply of concreted 
albumen, and to have been erroneously described as one of 
the characteristics of acephalocysts (hydatids). The interior 
of these cysts may likewise present the different varieties of 
false membranes which are found in the natural serous mem- 
branes. Although their internal membrane is generally sim- 
ple, it sometimes acquires a greater degree of complication, 
and detaches inwardly several processes, which may be com- 
pared to the reflections of the folds of the peritoneum. In 
this way are frequently formed in their interior a variety of 
septa or partitions, which separate and subdivide its cavity into 
several compartments, that sometimes communicate with each 
other, and are sometimes perfectly distinct. 

Cysts of this description, in general contain a limpid colour- 
less fluid, extremely variable in the relative proportions of the 
water, albumen, and salts which it contains. But there have 
been also found in them various other substances, which may 
be enumerated as follows. 1. Pure blood with its fibrinous 
coagulum and colouring matter. 2. A thin serous fluid, tinged 
with the colouring matter of blood, but containing no fibrine. 
3. Colourless serum with flocculi of fibrine floating in it. 4. 
A mucous fluid differing from albumen in being almost totally 
evaporated by heat. 5. A substance having all the physical 
and chemical properties of fat. 6. Cholesterine, another fatty 
production, which is found suspended in different fluids in the 
form of minute brilliant scales. 7. Several species of ento- 
zoa. 8. Some crystallized salts. 9. Different productions, 
solid as well as fluid, which have not as yet been observed ex- 



LESIONS OF NUTRITION. 187 

cept in those cysts ; some resembling caoutchouc, others pre- 
senting the characters of melanosis, having the consistence 
and colour of a thick solution of chocolate, and being proba- 
bly composed of blood in an altered state. 10. All the differ- 
ent varieties of pus. 11. Tubercular, or strumous matter, 
similar to that which is so frequently found in the lymphatic 
ganglions of scrofulous individuals. From this enumeration 
we may perceive, that there is a much greater variety in the 
products secreted by the accidental than by the natural serous 
membranes. 

It is by no means uncommon to find several of these pro- 
ductions existing together in different compartments of the 
same cyst. Thus, one of them may contain serum, the adjoin- 
ing one, blood ; and another pus, &c. It is in vain to search 
for any difference in the appearance, or in the anatomical char- 
acters of the parietes of the sac itself, or of its septa, to account 
for this singular difference in their productions : in all cases 
the same serous membrane will be found to be the source 
from which all these various productions are derived ; thus 
clearly establishing the important fact, that modifications of 
secretion do not always depend exclusively on appreciable 
modifications of texture. Is it not a curious phenomenon to 
observe in these multilocular cysts, the delicate membranes 
which form their partitions exhaling such different fluids from 
their two surfaces ? How is it that those fluids, produced as 
they are in almost actual contact, are not mixed together, and 
why is each of them poured into a distinct and separate cavity ? 

It was long a subject of debate, whether serous cysts were 
formed before or after the fluids they contained : the fact is, 
that either case may occur. For as no reasonable doubt can 
be entertained, that the serous cyst which is found round cer- 
tain effusions of blood, is subsequent in its formation to the 
clot which it surrounds ; so likewise, it is evident, that in those 
cysts with several compartments, in which so many, and so va- 
rious productions are found, contained each in a separate cell, 
the formation of the secreted product must have been pre- 
ceded by the formation of the secreting tissue which produced 



188 LESIONS OF NUTRITION. 

it. The solution of this question is really so simple, that I 
conceive it would be a waste of time to dwell on it. 



ARTICLE II. 

Of the Mucous Transformation. 

Batle recognized the existence of an accidental mucous 
membrane, lining the parietes of a fistulous passage, which 
formed a communication between the interior of the lung, and 
the sac of the pleura ; and before him, John Hunter in his 
Treatise on the Blood, and M. Dupuytren in his Lectures on 
Pathological Anatomy, had admitted the analogy which exists 
between the mucous membranes and those which line old 
fistulous passages. Laennec was also of the same opinion ; 
and, more recently, Doctor Villerme has published an excel- 
lent description of the lining membranes of fistulse, in which 
he has ably developed the great resemblance which sub- 
sists between them and mucous membranes. Professor Cru- 
veilhier has also described some cases of this kind. (Essai sur 
TAnatomie Pathologique, torn. ii.). M. Chaussier long ago an- 
nounced the fact of the existence of membranes studded over 
with villi, and similar to mucous membranes, lining the inter- 
nal surface of old abscesses which had no communication 
with the external atmosphere. Lastly, M. Cruveilhier and 
other anatomists admit the possibility of the reproduction of 
mucous membranes, after they have suffered a loss of sub- 
stance. In this latter case, as well as in those preceding, it 
must necessarily be the cellular tissue which insensibly changes 
its nature, and is gradually converted into mucous membrane. 

We have seen then, in the preceding paragraph, the exis- 
tence of accidental mucous membranes admitted in three prin- 
cipal cases. 1. In old fistulous passages, or in abscesses com- 
municating externally by such passages. 2. In abscesses 



LESIONS OF NUTRITION. 189 

which have no external communication. 3. In the place of 
portions of mucous membrane which had been previously de- 
stroyed. 

In this latter case, the conversion of cellular tissue into mu- 
cous membrane, appears to me perfectly established. In the 
first place, we have in favour of the possibility of such a trans- 
formation, the analogy of what takes place in the cutaneous 
surface under similar circumstances ; and, secondly, in proof 
of its reality, we have the direct observations of M. Cruveil- 
hier, (Op. Cit. torn. ii. pag. 170,) and other anatomists. It has 
been ascertained, that wherever the mucous tissue is destrov- 
ed, the adjacent cellular texture becomes, at first, vascular, 
then presents the appearance of a soft spungy membrane, 
studded over with minute vascular tufts, and at a still later 
period the transformation is complete, and no difference what- 
ever can be perceived between the original mucous mem- 
brane, and that which is newly formed. I think that I have 
succeeded in tracing the several gradations in the reproduction 
of the internal mucous membranes, to which my attention has, 
indeed, been more especially directed. In the first degree, the 
subjacent cellular tissue which has been exposed, presents a 
smooth surface and reddish colour ; this constitutes the pas- 
sage of a cellulo-vascular membrane into the most simple form 
of mucous membrane. In the second degree, this cellulo-vas- 
cular membrane is raised to the same level as the original mu- 
cous membrane, but cannot, like it, be detached from the sub- 
jacent tissues ; the arrangement of its vessels is less complica- 
ted ; and its surface presents no appearance of villi. In the 
third degree, it becomes perfect mucous membrane ; may be 
detached from the subjacent tissues ; and, in the alimentary 
canal, its surface is studded with villi. 

If, then, cellular tissue is susceptible of being converted into 
mucous membrane, in order to repair a loss of substance, is it 
not possible, that it may undergo a similar transformation, un- 
der other circumstances ; as for instance, when it has to per- 
form the functions of a mucous membrane, in consequence of 
being placed in contact with a foreign body ? In this latter 
case, as well as in the former, the conditions of two of the 



190 LESIONS OF NUTRITION. 

laws of transformation, laid down at the commencement of 
this chapter, are fulfilled. It may, however, be reasonably- 
questioned, whether this species of transformation, which has 
been admitted by so many authors of the highest respectabili- 
ty, is in reality perfect and complete ; or whether the name of 
mucous membrane has not been too hastily applied to cellular 
tissue injected and condensed into the form of a membranous 
layer. If the reality of this transformation be admitted, to 
what degree may it attain ? Does the accidental mucous 
membrane resemble only the very simple mucous tunic which 
lines certain excretory ducts? or is it capable of attaining the 
complex structure of the lining membrane of the air passages, 
or of the alimentary canal ? In order to solve these questions, 
it is necessary to compare the anatomical characters of those 
membranes which are found lining certain abscesses, and, 
more especially, old fistulous passages, with those of the nat- 
ural mucous membranes. 

Mucous membrane may be defined as a spongy layer, sup- 
plied with numerous blood-vessels, laid over a dense cellular 
tissue, from which it may be detached in the form of a mem- 
brane ; in some parts covered with an epithelium or cuticle, 
in others with villi ; having its surface studded with follicles, 
and secreting a particular fluid known by the name of mucus. 
Of these different parts, some are constantly present, others 
are occasionally absent, and yet the part does not lose its claim 
to the rank of a mucous membrane. This latter circumstance 
is important to be borne in mind, when instituting a compari- 
son between these membranes and certain membranous layers 
which are produced in the morbid state ; for it is evident, 
from what has been just remarked, that these accidental mem- 
branes may be regarded as appertaining to the mucous class, 
although deficient in some of their anatomical characters. Let 
us now proceed to examine the composition of these accidental 
mucous membranes, as they are called. 

I have frequently found on the surface of cavities contain- 
ing large collections of pus, and of old fistulous passages, a soft 
spongy layer, of a velvety appearance, possessing neither dis- 
tinct fibres, nor cells, destitute of elasticity, scarcely, if at all, 



LESIONS OP NUTRITION. 



191 



extensible, and in some cases, colourless, in others, liberally 
supplied with a network of vessels. The membranes on which 
these vessels were distributed, were sometimes of a pale red, 
or of a deeper shade of that colour, grey, slate-coloured, brown, 
or even black. This description is in every respect analogous 
to that of a mucous membrane, in its healthy state ; or when 
suffering under an acute or chronic attack of sanguineous con- 
gestion. The membranous layers which I have just described, 
present the same varieties of thickness as the natural mucous 
membranes. There are some, for instance, which are excee- 
dingly delicate, and scarcely equal in thickness the membrane 
which lines the frontal sinuses ; others, again, equal, or even 
exceed in this respect the mucous coat of the stomach. They 
rest on a layer of cellular tissue which is in general remark- 
ably compact, and not unfrequently approaches the density of 
fibrous tissue, in this respect exhibiting an analogy to the cel- 
lulo-fibrous layer, which every where lines the natural mucous 
membranes. It is in many cases impossible to detach them 
from this subjacent layer, with which they are in fact incorpo- 
rated, and seem to constitute its most superficial stratum, only 
differing from the layers underneath, in exhibiting a greater 
degree of vascularity ; thus representing the structure of the 
skin, whose vascular layer cannot be separated from its sub- 
jacent tissue unless by the imagination, and of some of the nat- 
ural mucous membranes, which are so intimately united with 
the tissues situated underneath, as to render it impossible to sep- 
arate them, without injuring one or other. There are, how- 
ever, some cases, in which there is no difficulty whatever in 
detaching accidental membranes exhibiting all the characters 
above described, from the parietes of the cavity they line ; and 
there is then found beneath them the cellular layer, which has 
been already mentioned. Some anatomists have found, in old 
fistulous passages, an exceedingly delicate membrane, lining 
the false mucous membrane, and insensibly terminating at a 
certain distance from its cutaneous orifice, thus accurately rep- 
resenting, both in appearance and situation, the epithelium of 
the natural mucous membranes. 



192 



LESIONS OF NUTRITION. 



No mention, that I am aware of, has been made of the exist- 
ence of follicles in any of those false membranes which have 
hitherto been described as appertaining to the mucous class ; 
and in the dissections which I have myself made, I have never 
been able to detect their presence, although I searched most 
minutely for them. Should we consider this absence of fol- 
licles, a sufficient reason for disallowing the right of these pro- 
ductions to rank as accidental mucous membranes ? To this I 
reply, that, in many parts of the natural mucous membranes, 
the existence of follicles is equally doubtful, and that if we ad- 
mit it, it can be only from analogy, supposing them too small 
to be perceived. In fact it would be absurd to imagine that 
the mode of organization which constitutes a mucous mem- 
brane is changed because the depressions it presents are less 
numerous or less apparent. 

The absence of villi can scarcely be considered a sufficient 
reason for excluding the membranes of fistulse from the class 
of mucous membranes ; for, even in the natural membranes, 
these villosities do not exist except in one, in that, namely, 
which lines the stone and small intestine ; and even there they 
are not visible during the earlier period of foetal life. If one 
of those false membranes taken from a fistulous passage or ab- 
scess, be examined under water, it generally presents a smooth 
surface, similar to that of all the mucous membranes except 
the digestive. Occasionally, however, the false membrane 
does not present this smooth aspect, but, when plunged into 
water, seems studded over with a number of minute filaments, 
which have neither the form nor the regularity of arrange- 
ment of the intestinal villi, but bear a much stronger resem- 
blance to the filamentous appendices attached to the tongue 
of certain animals. On close examination they have appeared 
to me principally composed of parcels of minute vessels eleva- 
ted perpendicularly above the surface of the membrane. 

To sum up, we do not find follicles and villi in every part of 
the natural mucous membranes, and consequently their absence 
or presence cannot be considered a sufficient reason for refu- 
sing or allowing the membranes of fistulas, &c. to be ranked in 
the class of mucous membranes. The essential characteristic 



LESIONS OP NUTRITION. 193 

of these membranes is the faculty they possess of secreting 
mucus ; it therefore becomes a point of importance to deter- 
mine whether this fluid has been found in fistulous passages. 
It is extremely difficult to ascertain this point satisfactorily, 
because various fluids generally pass through these fistulas, 
and unite with any mucus which may exist there. The puru- 
lent matter, too, which is secreted by the walls of the fistulae, 
may readily be mistaken for mucus. However, M . Villerme 
states positively, that he has frequently seen chronic fistulae, 
not at the time in a state of irritation, furnish a viscid glairy 
fluid, perfectly identical with mucus ; and that he has also 
seen these fistulous secretions present all the varieties which 
are usually observed in the healthy or morbid secretions of 
the true mucus membranes ; as for instance, all the various 
appearances which are presented in the discharge from the 
urethra in a state of acute or chronic inflammation. I recol- 
lect having observed in a case of necrosis of a rib, in a phthis- 
ical patient who came under my observation in the year 1819, 
that a viscid ropy fluid, of a greyish white colour, like the 
mucus of the nasal fossae, constantly exuded from the orifice 
of the long fistulous passage which led to the carious bone. I 
submitted this fluid to some chemical tests, and obtained the 
following results. It was slowly dissolved in water, but the 
solution did not coagulate by heat ; consequently it was not 
albumen : it. did not form a jelly on concentration, nor on ex- 
posure to cold ; so it could not be gelatine. The infusion of 
nutgalls caused no precipitate, as it should have done, if the 
solution contained either albumen or gelatine ; on the contra- 
ry, a precipitate was caused by the acetate of lead, which 
produces no such effect on either of these substances; and, 
lastly, it was precipitated from its watery solution by alcohol. 
These are the different characters which chemists assign to 
mucus. They were not, however, constantly present, but va- 
ried from day to day ; and the appearance of the secretion 
was altogether as variable as its chemical composition, and in 
some degree, seemed to coincide with it. Yet, the secreting 
membrane remained constantly the same, and the only varia- 
tion could be in its vital properties, in the quantity of blood 
Vol. I. 26 



194 LESIONS OF NUTRITION. 

which it received, and in its mode of elaborating that blood 
to separate from it those different secretions. The diseased 
bone might likewise have furnished different principles, which 
would no doubt modify the composition of the secretion. 
Such are the difficulties that must ever be experienced in in- 
vestigations of this description ; but, in the present case, there 
is still another, for we now know that the composition of mu- 
cus itself is not uniformly the same in all parts of the body, 
but presents some variety in each of the different membranes 
which secrete it. According to the situations where it is ex- 
amined, mucus is found to contain, in addition to the matter 
sui generis which characterizes it, and which Berzelius calls 
mucous matter, various principles, extremely different from 
each other, which by their combination with the true mucous 
matter, produce the most remarkable varieties in its physical 
and chemical properties.* To the physiologist acquainted 
with these circumstances, it cannot appear a matter of sur- 
prise, that the membranes of fistulas, although organized like 
mucous membranes, do not always present an identical fluid 
as the product of their secretion, or even a fluid similar to 
that exhaled by any particular portion of the natural mucous 
membranes.f 

From the facts we have stated on this subject, the following 
conclusions may be drawn. 

1. The cellular tissue which exists in the wal.ls of chronic 
abscesses, or old fistulous passages, may put on an appearance 



* Thus, for instance, if we are to believe Bostock, there is nothing easier 
than to distinguish between gelatine, albumen, and mucus, by the different ef- 
fects produced on these substances, by infusion of galls, corrosive sublimate, 
and acetats of lead ; M. Chevreul, however, no bad judge in subjects of this 
nature, does not agree with him, because he considers there has not been suf- 
ficient allowance made for the effects of other substances which accompany 
them in the fluids in which they are dissolved. (Diet. Des Sciences Naturelles, 
vol. xxxiii. page 72.) 

t According to M. Chevreul, new researches are absolutely necessary to de- 
cide whether mucus is a species or a genus containing species, or whether we 
have not confonnded under the same name substances quite too distinct to be 
considered as belonging to the same genus. — Diet. Des Sciences Nat. vol. hi. 
page 273. 



LESIONS OF NUTRITION. 195 

similar to that of certain mucous membranes. I think, not- 
withstanding, that Meckel has gone too far in comparing every 
suppurating surface to an imperfect mucous membrane. 

2. In this transformation, we must admit several gradations, 
according as the cellular tissue, not yet having arrived at the 
form of a membrane, presents only a series of vascular granu- 
lations, or, as it advances to a cellulo-vascular layer still insep- 
arable from the adjacent tissues, or finally, as it attains the 
rank of a distinct membrane which may be easily detached, 
and which, in some cases, presents a smooth, in others a fila- 
mentous surface. 

3. Neither follicles, nor villi similar to those found in the 
intestines, have ever been discovered in any of these accidental 
membranes. 

4. The circumstances which influence the composition and 
production of the fluid secreted by these membranes, are too 
complicated, and, as yet, too little understood, to authorize us 
in determining the nature of the secreting membrane from the 
nature of the fluid it secretes. 

5. These membranes, in their most perfect state of organi- 
zation, can only be compared to the most simple mucous mem- 
branes, such as those which line the ureters and the minute 
ramifications of the biliary ducts. 

6. No accidental mucous membrane has as yet been ob- 
served, which could admit of comparison with the complex 
structure of the gastro-intestinal mucous membrane. 

The lining membrane of fistulous passages presents several 
appearances which may contribute to prove its analogous na- 
ture with that of the true mucous membranes. When it is 
not in a state of irritation, it presents the pale greyish aspect 
of a mucous membrane in its healthy state ; when, on the con- 
trary, its local action is excited, we find in it the same shades 
of vascular injection, as in the natural mucous membranes, 
when suffering under an acute or chronic process of irrita- 
tion. Different morbid affections also, which are almost ex- 
clusively confined to mucous membranes, such as vegetations, 
fungous excrescences, callosities, &c. are likewise found on the 
walls of old fistulae. The cellular tissue immediately subja- 



196 LESIONS OP NUTRITION. 

cent to this lining membrane may become thickened and in- 
durated so as to answer to the description of scirrhus in the 
true submucous cellular tissue. Lastly, as adhesions are never 
formed between the parietes of a cavity lined with mucous 
membrane, unless where there has been a solution of its con- 
tinuity, so likewise, when we desire to produce adhesion be- 
tween the parietes of a fistula, in order to obliterate its cavity, 
it is necessary to make incisions through the lining membrane, 
and bring the subjacent tissues into contact. 

The formation of such accidental membranes as I have now 
been describing, is not confined to those parts of the cellular 
tissue which are free and uncombined ; similar membranes 
have likewise been observed in the substance of parenchyma- 
tous organs. I have cited some cases of this description in 
the 4th vol. of the Clinique Medicate, in my observations on 
abscesses of the liver. I once found in one of the hemis- 
pheres of the brain, two cavities filled with pus, and connect- 
ed by a fistulous passage : their internal surface, as well as 
that of their fistulous communication, was lined by a delicate 
membrane of a greyish red colour, soft and smooth to the touch, 
and susceptible of being easily detached in shreds from the 
subjacent tissue, as if it were merely laid on it. When ex- 
amined under water, it presented a villous appearance, and 
seemed to be studded over with minute filaments. The cere- 
bral substance in its vicinity presented its natural appearance. 
I have sometimes seen the parietes of ovarian cysts composed 
of a membrane which bore a much stronger resemblance to a 
mucous than a serous membrane : the same remark has also 
been made by Meckel. I once found in the kidney of a horse, 
a cyst of the size of an orange, filled with a whitish viscid fluid 
like the white of an egg. The walls of this cyst were com- 
posed of two distinct membranes ; the outer one was fibrous, 
the inner, of a soft spongy texture, and greyish colour ; view- 
ed under water it presented all the characters of mucous 
membrane, nor was there the slightest difficulty in detaching 
it from the external coat. In this case the structure of the 
cyst corresponded with the nature of the fluid it contained, 



LESIONS OF NUTRITION. 



197 



and both agreed in establishing the mucous nature of the lining 
membrane. 

Lastly, these accidental membranes presenting the mucous 
character may be formed in the false membranes secreted by 
the serous tissue; as appears from the following case. A boy, 
three or four years of age, died at the Hospital des Enfans, 
with all the symptoms of chronic peritonitis. I should remark, 
that close to his umbilicus there existed an orifice, through 
which, during life, there was a constant discharge of foetid 
mucus. The body was examined in my presence by Doctor 
Senn, of Geneva, who was then an intern pupil at the hos- 
pital. The different portions of the peritoneum were united 
by an infinite number of cellular adhesions; in the midst of 
which we discovered a well defined fistulous communication, 
of about two inches long, leading from the umbilical orifice 
already mentioned, to the interior of one of the coils of the 
small intestine. This duct was lined throughout by a smooth 
reddish membrane, in every respect similar to mucous mem- 
brane. There was no difficulty in detaching it from the sub- 
jacent parts formed by the cellular adhesions. It was contin- 
uous at one end, with the mucous membrane of the intestine, 
and at the other, with the skin. 



ARTICLE III. 

Of the Cutaneous Transformation. 

When the skin has suffered a solution of continuity with 
loss of substance, a process of active hypersemia is set up in 
the sub-cutaneous cellular tissue, the result of which is the 
production of a new tissue more or less analogous to that 
which had been destroyed. In general the newly formed skin 
is incomplete, being only composed of a cellulo-fibrous layer, 
similar to the corium, and of the epidermis. When thus con- 



198 



LESIONS OF NUTRITION. 



stituted, it is of a duller white colour than the surrounding 
skin, and evidently wants the vascular layer in which the col- 
ouring matter is deposited: this deficiency is particularly 
evident in the negro, the cicatrices of whose skin are fre- 
quently white, and continue so always. Sometimes, however, 
the newly formed skin differs in no respect from the rest of 
the cutaneous envelope ; having, though at first very dissimi- 
lar, become insensibly assimilated to it. In this way, cica- 
trices, which were long remarkable for their extreme pale- 
ness, have subsequently been seen to assume a more natural 
colour, and sometimes to acquire even a deeper shade of 
red than the surrounding skin, in which case we may suppose 
either that an increased secretion of colouring matter has 
been produced by the temporary excitation of the nutritive 
action of the part; or, that the deep colour of the cicatrix de- 
pends on the retardation of its capillary circulation, as has al- 
ready been explained in Section I. 

When a mucous membrane is accidentally exposed to the 
air, and continues for some time in this state of exposure, we 
observe a series of remarkable changes in its colour, which 
becomes gradually paler; in its consistence, which increases 
considerably; and in its organization, which constantly ap- 
proaches that of the skin. Anatomy has not as yet demon- 
strated in those mucous membranes which are apparently con- 
verted into skin, the existence of those different layers which 
taken together, constitute the true cutaneous tissue. 



ARTICLE IV. 

Of the Fibrous Transformation. 

The fibrous productions, so named from the strong analogy 
which they bear in their structure and properties to the 
natural fibrous tissue, are one of the morbid growths which 



LESIONS OP NUTRITION. 199 

are most evidently formed at the expense of the cellular tissue, 
for we can trace this tissue through all the successive grada- 
tions of its metamorphosis, until it finally attains the rank of 
perfect fibrous structure. It, however, retains, for a long 
time, a certain degree of softness and extensibility, and par- 
takes of the nature of both tissues, so that it may be denom- 
inated cellulo-fibrous. Such is also the state in which the 
fibrous tissue is found in the embryo; and in the adult, where 
it has undergone a solution of continuity. In both these cases, 
as well as in the formation of fibrous tissue where it does not 
naturally exist, we shall find, on tracing its formation to its 
source, that cellular tissue had previously existed where the 
fibrous tissue is subsequently developed. 

The structure of the accidental fibrous tissue presents 
greater varieties than that of the natural. It is composed of an 
assemblage of delicate filaments, which are sometimes parallel, 
sometimes interlaced and matted together, and sometimes 
rolled up, coiled, or convoluted. Between these filaments there 
exists some cellular tissue which may occupy either more or 
less space than the fibrous tissue. According to the mutual 
arrangement of these two tissues, the latter (the fibrous) may 
present a continuous whole, or may assume the form of bands, 
isolated patches, or of small, round, or irregularly shaped 
bodies, disseminated through a mass of cellular tissue, which 
may itself be either dry, or saturated with serous Huid, colour- 
less, or traversed by a number of minute red vessels. There 
are some cases in which the cellular tissue is scarcely, if at all, 
perceptible, and the fibres are so condensed and agglutinated, 
as to present to the eye the appearance of a homogeneous 
mass; by maceration, however, they may be made to appear. 
The vessels which are distributed on these fibrous productions, 
in general belong to the cellular tissue which enters into their 
composition; but in some cases they seem to penetrate the 
fibrous tissue itself, which, in a few instances, has even been 
found exceedingly vascular. In this respect, accidental fibrous 
tissue may be divided into three classes, corresponding to those 
of the natural fibrous tissue, which is sometimes entirely desti- 
tute of red vessels, sometimes receives only a few, and some- 



200 



LESIONS OP NUTRITION. 



times, again, is exceedingly vascular, as is emplified in the 
periosteum. 

Accidental fibrous tissue may be divided, with respect to its 
physical properties, into imperfect and perfect. The first par- 
ticipates more or less of the qualities of cellular tissue, and in 
this respect approximates, as I have already remarked, to the 
structure of the fibrous tissue in the foetus. It possesses a cer- 
tain degree of softness, which allows it to be easily torn asun- 
der, crushed, or reduced to a pulpy mass; it possesses con- 
siderable extensibility, yields, when cut or pressed, a consider- 
able quantity of fluid, and is readily dissolved in boiling water. 
On the other hand, the accidental fibrous tissue which may be 
denominated perfect, is remarkably hard and tenacious, con- 
tains less humidity than the preceding, and is also less soluble 
in water at 212° Fahrenheit. It is of a dull white, of a bluish, 
pearly, or silver white, of a yellowish tint, or of a red, more or 
less deep. 

Accidental fibrous tissue is principally met with in the fol- 
lowing forms. 

1. The funicular form. In this case, it appears arranged in 
irregular fasciculi; or else in the form of bands traversing 
masses of cellular texture, and interposed between the different 
organs, or parts of the same organ ; or, finally, in circular cords 
surrounding the margins of various apertures. 

2. The membranous form. Under this form we frequently 
find a variety of laminae, partitions, and layers composed of 
accidental fibrous tissue, and even complete envelopes, analo- 
gous to the natural aponeuroses, and capsules. These fibrous 
expansions often form an additional layer round other accident- 
al tissues, particularly those of the serous and mucous class. 

3. The tumour form. Accidental fibrous tissue developed in 
this form may be divided, with respect to its texture, into three 
varieties. 

First variety. A tumour, homogeneous in its composition 
through its whole extent. The fibres are very much condens- 
ed, and do not seem to be separated by any layers of cellular 
tissue. 

Second variety. A tumour divided into lobules of various 



LESIONS OF NUTRITION. 201 

shapes and sizes ; the interposed cellular tissue being either 
loose, or condensed, colourless, or injected. These lobules 
sometimes present no appearance of distinct fibres, but, in 
other instances, they are evidently composed of numerous fila- 
ments mutually interlaced and matted together, or else rolled 
up regular round masses. 

Thh'd variety . A tumour formed by an assemblage of lob- 
ular granulations separated by cellular tissue. These granu- 
lations may be again subdivided into others of smaller size. 
They are sometimes arranged in such a manner as to give the 
tumour a remarkable resemblance to the structure of the sali- 
vary glands and pancreas. The tumours denominated pan- 
creatoid by M. Maunoir of Geneva, and which he considers 
as a morbid degeneration, sui generis, appear to me simply 
fibrous growths belonging to this third variety. 

Accidental fibrous tissue, when arrived at its perfect state, 
or even before that period, not unfrequently undergoes differ- 
ent modifications of nutrition, which alter its texture to a 
greater or less degree. Of these modifications, some appear 
to consist simply in the continuation of the preternatural ex- 
citement of the local nutrition, which, after creating fibrous 
tissue, where only cellular should naturally exist, subsequently 
produces cartilage, and eventually a deposit of ossific matter. 
These different modifications in general occur without any con- 
comitant pain, and without exciting any morbid sympathies, or 
reaction, in the system at large. But, in other cases, after an 
acute or chronic attack of active hyperaemia, another class of 
morbid changes takes place, which may affect either the fibrous 
tissue itself, or the cellular tissue which enters into its com- 
position and serves to separate its constituent parts. The cel- 
lular tissue becomes injected and swollen, and then suppurates 
and becomes the seat of different morbid secretions ; while 
the blood which is determined towards the part sometimes es- 
capes from its vessels, and so produces either copious haemorr- 
hages, or effusions of fibrine, which may subsequently become 
organized, and give rise to different morbid productions. 
When the cellular tissue which enters into the composition of 
these fibrous growths becomes thus diseased, the minute fila- 
Vol. I. 27 



202 LESIONS OF NUTRITION. 

ments or lobules which it served to invest, become detached 
from each other, lose their natural consistence, assume a floc- 
culent appearance, and finally disappear altogether; so that 
after a certain period the tumour appears to have changed its 
nature. These diseases of accidental fibrous tissue, which are 
very different from the simple cartilaginous or osseous trans- 
formations it may also undergo, are generally accompanied by 
many of the symptoms, local, as well as general, which au- 
thors have attributed to cancer. 

The organs in which fibrous growths are accidentally de- 
veloped, may present any of the following conditions. 

1. They may be perfectly healthy. This case is by no 
means uncommon ; indeed it often affords matter of surprise 
to see the almost perfect degree of isolation in which certain 
fibrous tumours are found, with respect to the organs in which 
they are developed ; insomuch that they may with the great- 
est ease be separated from them, by breaking a few delicate 
cellular or vascular connexions, without in the slightest degree 
interfering with the texture of the organ itself, with which 
they appear simply contiguous. From what source are we to 
suppose that tumours thus circumstanced derive the materials 
for their growth and nourishment ? Does this mass of cellular 
texture, which by some modification of its nutrition has been 
converted into fibrous tissue, does it, I would ask, at the time 
of its conversion, acquire an independent vitality ? 

2. The organs may be the seat of an active hyperaemia, 
which may, or may not, be accompanied with other alterations 
of nutrition. In this case it is often difficult to decide whether 
the inflammatory action preceded the fibrous transformation, 
or was consecutive to it. 

3. They may have undergone a true atrophy ; or, in other 
words, the proper tissue of the organ may have disappeared, 
at the same time that the cellular tissue which entered into 
their composition, underwent the fibrous transformation. Thus, 
for example, I have sometimes found, especially in old horses, 
the pulmonary parenchyma in certain points replaced by 
fibrous masses ; the testicle has likewise been found trans- 
formed into fibrous tissue ; and a similar transformation has 



LESIONS OP NUTRITION. 203 

still more frequently been observed in the ovaries. In the 
case recorded by M. Magendie, in which the retina was trans- 
formed into fibrous membrane, I think it highly probable that 
this transformation occurred, not in the nervous expansion it- 
self, but in the fine cellular tissue which exists between it and 
the choroid. I am the more inclined to adopt this opinion, in 
consequence of the firm conviction I entertain, that such must 
also be the seat of certain osseous capsules, which are occa- 
sionally found in the bottom of the eye, and which are gene- 
rally considered as ossifications of the retina : in all such cases, 
the retina is reduced to a state of atrophy, but is never meta- 
morphosed into another tissue. 

In some cases, the portion of the organ which yields its 
place to the fibrous growth, is not simply reduced to a state of 
atrophy, but has been destroyed by some external violence, or 
other injury ; and the cellular tissue, whose business it was to 
furnish the proper materials for the reparation of the injury, 
has only supplied such as were fitted to form fibrous tissue. 
In this way are formed those fibrous productions which have 
been found in cicatrices of the skin, of the muscles, of the 
bones, and of the liver, and in the site of old fistulous passages 
which have been obliterated. 

In many cases of fibrous growths, it is easy to demonstrate 
the previous existence of irritation in the tissue, or organ, 
where this accidental production is formed. But in general 
this irritation is not followed by the appearance of an acci- 
dental fibrous production, unless under such circumstances as 
fulfil one or more of those laws which have been already laid 
down, as regulating the nature and mode of the transforma- 
tions of tissues. Thus, if a portion of fibrous tissue is divided, 
the irritation which necessarily succeeds, is followed by a re- 
production of this tissue. If the head of a bone is displaced 
from its natural situation, and placed in contact with another 
bone ; or, if the extremities of a fractured bone are not speedi- 
ly re-united, the irritation which follows these accidents pro- 
duces, in the first case, a fibrous capsule, and in the second, 
ligamentous bands by which the fractured extremities are re- 
united. In the same way, when a muscle is divided, its solu- 



204 LESIONS OF NUTRITION. 

tion of continuity is often repaired by accidental fibrous tissue. 
But in all these cases it will be found, on reference to the laws 
of transformation laid clown at the commencement of this chap- 
ter, that their conditions have been fulfilled. 

There are some cases, however, in which the production of 
fibrous growths, occurring as a consequence of irritation, can- 
not be referred to any of these laws. In the mean while, until 
we shall have discovered the laws which in such cases regu- 
late their formation, we must be contented to admit, as the 
simple enunciation of a fact, a peculiar pre-disposition, by vir- 
tue of which the same irritation which in one individual is fol- 
lowed by aberration or some other alteration of nutrition, in 
another gives rise to a fibrous transformation, of which, though 
it may be the occasional, it is not the essential cause. 

There is again another class of cases, in which we have no 
evidence whatever of this species of transformation having 
been preceded by any irritative action ; but in this there is re- 
ally nothing surprising. Have we not already seen that, in 
every morbid change, the only effect which can rationally be 
attributed to irritation, is the tendency to deviation from the 
natural type which it produced in the function of nutrition ? 
But reason and experience both prove, that this alteration may 
be as effectually produced by various other causes. For in- 
stance, I once saw the sterno-cleido-mastoid muscle of the right 
side wholly converted into a perfect fibrous tissue, exactly sim- 
ilar to the broad tendon in which it terminates inferiorly. In 
this case, the condition of the muscle previously to its trans- 
formation, was quite the reverse of that of a part labouring 
under increased vascular action, or irritation ; for, it had been 
for a length of time in a state of total inaction, in consequence 
of an attack of hemiplegia, accompanied with permanent con- 
traction of the left sterno-cleido-mastoid, under which the in- 
dividual had laboured for a number of years. The muscle 
was in this case converted into a fibrous organ, on the same 
principle, and probably by the same process, as that by which 
we frequently see, in the animal kingdom, fleshy parts con- 
verted into fibrous tissue, when the muscular contractility of 
the part has by some modification of function been rendered 



LESIONS OP NUTRITION. 205 

unnecessary. Several facts induce me likewise to think, that 
in certain cases of atrophied organs, there is a disposition to 
the formation of fibrous tissue in the room of the proper tis- 
sue of the organ which has disappeared. 



ARTICLE V. 

Cartilaginous Transformation. 

This species of transformation is, at least, as common as the 
preceding, and is found almost under the same circumstances ; 
in many cases the cartilaginous succeeds the fibrous transfor- 
mation. 

Cartilaginous productions are found, 1st. in the cellular tis- 
sue interposed between the different organs ; 2d. in some 
parenchymatous organs ; 3d. and lastly, loose and unattached 
in certain serous cavities. In the last two cases, they are 
sometimes found single and uncombined, sometimes they exist 
in combination with accidental fibrous or osseous tissues, and 
sometimes they enter as a constituent part into the composi- 
tion of tumours of various descriptions. 

I. Cartilaginous Productio?is developed in the Cellular Tissue. 

There are few parts of the cellular tissue which is inter- 
posed between the different organs, or tissues, in which 
the developement of accidental cartilages has not been ob- 
served. Thus, for instance, the cellular tissue which is sub- 
jacent to serous membranes is frequently the seat of these 
productions. Cartilage has been found in the form of isolated 
grains, large spots, and irregular incrustations ; in the cellular 
membrane which lines the arachnoid, the pleura, the pericar- 
dium, the peritoneum, the tunica vaginalis, and the synovial 



206 LESIONS OP NUTRITION. 

membranes. In these different situations, accidental cartilages 
may be found, 1. unattended by any other appreciable lesion; 
2. co-existing with different alterations of the serous mem- 
brane under which they are formed, such as adhesions, effu- 
sions, &c. ; 3. along with various morbid changes in the sub- 
stance of the organs which are enveloped by the serous tunic. 
In many cases of this description, it is possible to follow the 
different degress of modification which the texture of the cel- 
lular tissue undergoes during its transformation into cartilage. 
For example, behind the same pleura it is by no means un- 
common to observe some spots in which the cellular tissue is 
condensed and indurated, but still retains its natural organiza- 
tion ; others in which it is become evidently fibrous ; and 
lastly, others in which it presents merely a homogeneous 
white mass, the texture of which is perfectly analagous to that 
of cartilage. In such cases, we sometimes also find a serous 
fluid effused between the condensed laminas of the cellular 
tissue ; and, not unfrequently, a gelatinous yellow fluid, which 
has been set down as softened scirrhus. 

The submucous cellular tissue differs materially from the 
subserous in this respect ; for it is seldom, if ever, transformed 
into cartilage ; although it is constantly found in a state of 
hypertrophy and induration. I recollect having seen a soli- 
tary instance of a true cartilaginous mass developed in the 
subcutaneous cellular tissue of the stomach. This mass passed 
by insensible gradations into the adjacent cellular tissue, which 
was thickened and indurated. It cut precisely like a piece of 
costal cartilage. 

The sub-cutaneous and intermuscular cellular tissue may 
likewise undergo the cartilaginous transformation. One of 
the lower extremities ef a woman who died at La Charite, in 
the year 1820, was affected with elephantiasis. Underneath 
the skin, and occupying the place of the muscles, which were 
reduced to a few pale fibres, was found an enormous mass of 
condensed, hard, cellular tissue, containing here and there 
small cavities filled with serum, and possessing in many places 
all the physical qualities of cartilage. 



LESIONS OF NUTRITION. 207 

The cellular tissue interposed between the internal and the 
middle coats of arteries, is very frequently the seat of carti- 
laginous incrustations, which shall be described at length here- 
after. (Vol. II. Diseases of the circulating Apparatus.) Lastly, 
wherever cellular tissue exists free and uncombined with other 
tissues, accidental cartilaginous production may be developed 
either as amorphous solid homogeneous masses, or in the form 
of membranes, enveloping various morbid secretions, thus 
contributing to form cysts with cartilaginous parietes. The 
following cases present some remarkable examples. 

Case I. A cyst, with cartilaginous parietes, containing fatty 
matter and hair, developed between the layers of the mesen- 
tery. 

I found this cyst in a negress of 57 years of age. It was 
as large as an infant's head, and its parietes, which were per- 
fectly cartilaginous, were surrounded on the outside by an 
envelope of loose cellular membrane, which served as a me- 
dium of connexion between the cyst and the neighbouring 
parts. The matter it contained was like suet, and was mixed 
up with a great number of hairs. (For more ample details of 
this case see Clinique Medicale, torn. 4. p. 680.) 

Case II. A cartilaginous cyst, filled with matter similar to 
honey, found in the anterior mediastinum. 

In a middle aged man I once found, behind the sternum, in 
the situation occupied by the thymus in the infant, a tumour of 
the size of a small orange, which was hollow in the centre, 
and contained a fluid resembling honey. The parietes of this 
cyst were composed of three distinct layers : the interior pre- 
sented all the characters of serous membranes ; the exterior 
was cellulo-fibrous ; and the middle layer was perfectly carti- 
laginous. 

Case III. A multilocular cyst with cartilaginous parietes de- 
veloped in the neck of a female. 

This tumour, which was of considerable dimensions, was 
removed by M. Roux from the side of a woman's neck. On 
laying it open, I found its texture in some parts fibrous, in 
others, fibro-cartilaginous. These different tissues, arranged 
in laminae and septa of various forms and dimensions, divided 



208 



LESIONS OF NUTRITION. 



the interior of the cyst into a number of separate compart- 
ments or cells, containing a semifluid unorganized substance, 
not unlike a thick solution of starch. 

Case IV. A tumour of the same nature developed on a 
man's arm. 

M. Roux likewise removed this tumour, which weighed 
nearly nine pounds, from the arm of a man fifty years of age, 
in the hospital of La Clinique de Perfectionnement. On ex- 
amination it presented the following structure. The skin over 
the tumour was perfectly healthy ; the aponeurotic tissues sit- 
uated between the skin and the muscles appeared somewhat 
thicker than ordinary. The muscular fibres, spread in bundles 
over the surface of the tumour, were thin and pale-coloured. 
Immediately under this muscular expansion, I found a cellulo- 
fibrous layer, which completely surrounded the tumour, and 
formed a perfect envelope for it. The tumour, when felt 
through this layer, appeared firm and elastic, and in some 
points conveyed an indistinct sense of fluctuation. When 
cut into, it appeared at first principally composed of a grey 
semi-transparent substance, resembling starch in many of its 
physical characters ; and in several places presented the ap- 
pearance of being subdivided into a number of minute polish- 
ed grains clustered together. In the midst of this substance, 
which, as I have just described, was in some parts homogene- 
ous, and in others presented a granular structure, we found a 
number of septa or laminae composed partly of fibrous, and 
partly of cartilaginous tissue. These septa divided the inte- 
rior of the tumour into a number of cells or regular areolae in 
which the unorganized substance above described was depos- 
ited. In this manner, the whole of the tumour was divided 
into several compartments, each of which presented, 1st, a 
part containing, formed of fibrous or cartilaginous tissue ; and, 
2d, a part contained, formed of an unorganized substance ap- 
parently the product of secretion. In many points we found, 
instead of simple partitions, solid masses of considerable thick- 
ness, presenting all the characters of perfect cartilage, through- 
out the substance of which, calcareous matter was found de- 
posited ; and in some parts these calcareous deposits were so 



. LESIONS OF NUTRITION. 209 

crowded together, as to constitute considerable masses which 
could not be divided by the scalpel. 

A number of red vessels of considerable diameter were 
found in this tumour ; they were not, however, distributed 
indifferently to every part of it. Not one, for instance, was 
observed ramifying through the starch-like secretion ; on the 
septa or partitions, several were distributed ; but by far the 
greater number were found in the substance of the solid car- 
tilaginous masses, especially where the calcareous matter was 
deposited in them. 

The periosteum, which was in immediate contact with the 
tumour, was exceedingly vascular, but in other respects per- 
fectly natural. The external appearance of the bone was 
not at all changed, except in one part, where it presented a 
species of swelling or enlargement, the nature of which I shall 
presently describe. The interior presented some morbid 
alterations which were particularly interesting, from the stri- 
king analogy they presented to the alterations found externally 
in the soft parts. The medulla was replaced by a substance 
analagous to the accidental production above described, con- 
sisting of a starch-like matter contained in numerous cells, the 
partitions of which were composed of cellulo-fibrous tissue. 
The medullary membrane was red and thickened, and some- 
what fungous ; and was plainly visible on the internal surface 
of the bone. At a short distance from the head of the hu- 
merus, at its inner side, the morbid matter which had taken 
the place of the medulla, was found more abundantly than 
elsewhere, and had even insinuated itself between the fibres 
of the bone, and caused them to protrude externally ; in this 
manner the enlargement of the bone above alluded to was 
formed. 



II. Cartilaginous Productions developed in the Structure of 
Parenchymatous Organs. 

The observations which I have already offered respecting 
the accidental developement of fibrous tissue in parenchyma- 
Vol. I. 28 



210 LESIONS OF NUTRITION. 

tous organs, are equally applicable to the formation of car- 
tilaginous tissue : they both seem to be formed at the ex- 
pense of the cellular substance which enters into the composi- 
tion of these parts. When cartilage is accidentally developed 
in the substance of an organ, it may either assume the form of 
an envelope containing various morbid secretions, between 
which and the surrounding parts it forms a sort of barrier ; or 
it may be deposited in amorphous masses, which occupy the 
place of parts of organs that had previously been destroyed. 

It is exceedingly rare to find any tissue except the cellular 
undergoing a real transformation into cartilage. Thus, al- 
though we constantly observe the formation of plates of car- 
tilage, immediately under the serous membranes, there is not 
a single case on record, in which the serous membrane itself 
has been converted into that substance ; and thus, also, when 
these same plates or patches are found on the surface of the 
liver, or spleen, or between the serous and fibrous layers of 
the pericardium, or even between the arachnoid and dura 
mater, it is invariably between these membranes that this 
transformation takes place, and not at the expense of either 
of them. In like manner, the cartilaginous incrustations found 
in the arteries are invariably formed between their middle and 
internal tunics, which are never themselves transformed, 
though they may present other morbid alterations. The cel- 
lular tissue subjacent to the mucous membranes is sometimes, 
though rarely, transformed into cartilage ; nor are these mem- 
branes themselves totally exempt from this species of trans- 
formation. Laennec relates a case of a child, in the mem- 
branous portion of whose urethra was found a urinary calculus 
of the size of a hen egg. The mucous membrane of the part 
presented several white patches of the size and thickness of a 
nail, which in their texture appeared to him semi-cartilagin- 
ous ; and he adds, that they were evidently incorporated with, 
and formed a part of the mucous membrane. In a case of 
prolapsus uteri, Beclard found the mucous membrane of the 
vagina in like manner studded over with a number of small 
cartilaginous spots; and he also observed a similar appearance 



LESIONS OF NUTRITION. 211 

on the prepuce of an old man, who had had phymosis from 
the time of his birth. 

The osseous tissue may likewise undergo such a modifica- 
tion in its nutrition, that its cellular network shall receive a 
deficient supply of calcareous matter, and shall separate from 
the blood the materials necessary for the formation of carti- 
lage. Beclard used to mention in his lectures the case of an 
old woman, who had a horny excrescence on her forehead, at 
the base of which the bones of the skull were converted into 
cartilage. Several authors have spoken of the metamorpho- 
sis of muscle into cartilage : there is certainly no more dif- 
ficulty in supposing the possibility of such an occurrence, than 
of the conversion of muscle into fibrous tissue, of which I 
have already given a remarkable example ; but, in reality, I do 
not think that a genuine case of this description has as yet 
been observed, inasmuch as all those cases of cartilaginous 
transformation of the diaphragm, which are recorded in va- 
rious authors, appear to me nothing more than cases of carti- 
laginous incrustations, formed on the superior or inferior sur- 
face of that muscle. The muscles of animal life ma}' be sep- 
arated, compressed, diminished, or reduced to a state of atro- 
phy, by means of cartilage developed between their fasciculi ; 
but I am not aware of any well authenticated case, in which 
the muscular fibre itself has been found converted into carti- 
lage. The cartilaginous transformation of the fleshy substance 
of the heart, is, in my opinion, equally doubtful. Perhaps we 
may, without incurring the imputation of scepticism, be per- 
mitted to doubt the accuracy of Columbus' observation, in 
the case he records, of his having seen the septum of the ven- 
tricles converted into cartilage ; and 1 am disposed to think, 
that what has generally been described as cartilaginous trans- 
formation of the heart, is, (at least in a great majority of cases,) 
merely a deposition of cartilage, either on the external sur- 
face of the heart, between it and the pericardium, or, on its 
internal surface, in those parts where layers of cellular or fi- 
brous tissue naturally exist. The manner in which cartilage 
is formed in the thyroid gland, requires to be further elucida- 
ted by additional observations. With respect to the cartilagi- 



212 LESIONS OF NUTRITION. 

nous transformation of some other parenchymatous organs, 
such as the brain, liver, lungs, spleen, kidneys, uterus, and tes- 
ticles, I do not think it better established than that of the 
heart ; and in all these cases, the developement of cartilage 
in the cellular tissue which invests or enters into the compo- 
sition of the respective organs, has frequently been mistaken 
for the conversion of their proper texture. If, however, I 
were to name any parenchymatous organ, in which my own 
observation would induce me to admit the reality of this trans- 
formation, I should decidedly say, the brain. My friend Doc- 
tor Blandin and I once found, in a little girl about two years 
old, several convolutions on the superior surface of both lateral 
hemispheres in a state of extreme induration. When strongly 
compressed between the fingers, they offered the same resist- 
ance as cartilage, of which substance they also presented the 
elasticity, the homogeneous texture, and the ivory-white colour. 
In the centre of both hemispheres, and at the base of the brain, 
we found several other parts in the same indurated state. This 
child, during the whole time of her stay in the hospital, pre- 
sented no remarkable alteration in any of the actions of ani- 
mal life, except a constant oscillation of the head from one 
side to the other. In this case there were also some morbid 
appearances found in the cerebellum, but they were foreign 
to the present subject. 



III. Cartilaginous productions existing loose in Cavities. 

These have been principally observed in those cavities which 
are lined by serous and synovial membranes. Sometimes 
they are perfectly isolated ; in other cases they are attached 
by a membranous prolongation, or pedicle, to some point of 
the parietes of the cavity in which they are situated. Their 
form may be either spherical, oval, flattened or irregular. 
Their size is in general not considerable ; some, for instance, 
are scarcely as large as the head of a pin, and I am not aware 
that any have been found exceeding the dimensions of a pea, 
or, at the largest, of a bean. They are composed of an elas- 



LESIONS OF NUTRITION. 213 

tic, homogeneous substance, similar to cartilage ; and it is not 
uncommon to find some osseous points disseminated in their 
interior. I recollect having once found in the centre of one 
of them, a cavity filled with a sebaceous substance. The pro- 
duction to which I allude, was found floating loose in the sac 
of the peritoneum. Laennec has seen some of them, which 
were divided into several lobules, connected by fibrous, or cel- 
lular tissue. The knee-joint is the one in which these cartila- 
ginous secretions have been most frequently observed ; they 
have likewise been found in the articulations of the lower jaw, 
of the ankle, of the head of the fibula with the tibia, and of 
the pisiform with the cuneiform bone. They have not been 
observed by Laennec in any of the serous membranes, except 
in the tunica vaginalis testis ; but he mentions having seen one 
on the external surface of the arachnoid, where it lines the 
lateral ventricles. I have myself seen three of these bodies 
in the serous membrane of the brain : one of them floated 
loose and unattached, in the sac of the arachnoid ; the other 
two were attached to the choroid plexus, by a delicate cellu- 
lo-vascular prolongation. I have never met with either of 
them in the pleura, or pericardium ; but I have often found 
them in the peritoneum, sometimes perfectly isolated from all 
the solid parts, and at other times appended to a peculiar pro- 
longation of the serous membrane. Littre likewise mentions 
having found a cartilaginous body floating loose in the perito- 
neal cavity. 

It was for a long time supposed, that these concretions were 
formed of fragments of cartilage, detached from the articu- 
lating surfaces of the joints in which they were found ; but, 
in addition to the objections which this supposition is liable to, 
from the form and texture of these bodies, it is totally sub- 
verted by the fact of their having been found in serous mem- 
branes also. Are we then to suppose that they derive their 
origin from the fluid which is exhaled in these serous and sy- 
novial cavities ? this mode of accounting for their origin, is 
certainly far from being absurd, and may be supported by some 
strong analogies. Another origin, and apparently a more prob- 
able one, has, however, been assigned to these concretions by 



214 



LESIONS OF NUTRITION. 



Laennec and Beclard. They suppose that these bodies are 
not originally formed in the cavities where they are found, but 
on the external surface of the serous or synovial membrane, 
which they gradually protrude before them, so as to transform 
that portion of the membrane behind which they were situa- 
ted, into a prolongation or pouch in which they become envel- 
oped. In this way (say they) is formed that variety of these 
concretions which is attached, as it were, by a foot-stalk, to 
the parietes of the cavity ; and in order to account for the 
the other variety, they add, that, at a subsequent period, a so- 
lution of continuity takes place, the concretion becomes de- 
tached from the serous membrane, and drops into the cavity. 
Laennec has followed all the degrees of the displacement of 
these concretions, in the tunica vaginalis, from the incipient 
stage in which they form a slight projection behind the serous 
membrane, to the period when they become perfectly isolated 
bodies. 

I do not pretend to deny, that those concretions may be 
occasionally formed in this manner ; but I feel thoroughly 
convinced that their origin is in some cases very different. 

In fact, it is not alone in serous membranes, or in the joints, 
that isolated cartilaginous bodies are found. I recollect hav- 
ing found one as large as a pea, in the midst of the adipose 
tissue of the orbit. Another has been found by Professor 
Fizeau, in the interior of the globe of the eye, between the 
capsule of the crystalline lens and the layer of the hyaloid 
membrane which invests its posterior surface. I have like- 
wise found, in two individuals, serous cysts containing a num- 
ber of these cartilaginous concretions, floating without any 
attachment in a serous fluid, which, in one case, was limpid 
and colourless, and in the other was turbid and of a dirty grey- 
ish colour. The first of these cysts, of about the size of a 
walnut, was situated along the course of one of the spermatic 
cords, and contained five cartilaginous bodies, the largest of 
which scarcely equalled the size of a small pea. The second 
was found in the pelvis of an old woman, where it was at- 
tached to the fimbriated extremity of the Fallopian tubes ; 
it was about the size of a hen egg, and contained eight little 



LESIONS OF NUTRITION. 215 

round cartilaginous concretions. Is it not highly probable that 
in these, and other such cases, those concretions are formed in 
the midst of the fluid in which they are found ? 



IV. Cartilaginous Productions supplying the Place of Natural 
Cartilages that had been destroyed. 

In many cases, where cartilages have suffered a solution of 
continuity, we do not observe any process established for the 
reparation of the injury ; sometimes, again, the loss of sub- 
stance is repaired by the deposition of osseous matter, as is not 
unfrequently seen in fractures of the costal cartilages ; and 
sometimes, lastly, a new cartilage is formed for that purpose. 
This latter mode of reparation has been particularly described 
by Laennec in the cartilages of the articulating surfaces. 
" These new cartilaginous productions," he remarks {Diet, des 
Sciences Medicales, art. Cartilage Accidentel) "are thinner 
than the old cartilage, with which however they are contin- 
uous ; they consequently have the appearance of being de- 
pressed, and their tenuity is often so great, that, from their 
transparency, the bone over which they are situated imparts 
to them a violet tinge. It is not uncommon to find fringed 
prolongations of the old cartilage covering the new tissue 
without adhering to it." 

I really do not see any satisfactory evidence of the existence 
of a newly formed cartilage in this description of Laennec. 
Is it not just as probable, that those thin plates which he de- 
scribes may have been the old cartilage partially thinned, and 
reduced to a state of atrophy, as that they are an accidental 
production ? Be that as it may, this species of alteration which 
Laennec calls a cicatrix, is, according to his statement, of 
very frequent occurrence ; from whence he concludes, that 
the erosions to which it succeeds are not in all cases a very 
serious affection. We might ask, what proof there is of such 
erosions having ever existed. He also remarks, that this alter- 
ation is almost uniformly found in several joints at once. 

Accidental cartilaginous productions present several varie- 



216 



LESIONS OF NUTRITION. 



ties of form, which in general correspond with the varieties of 
their situation. For example, when they are developed round 
the head of a bone dislocated from its socket, they assume the 
form of articular cartilages. When deposited round certain 
accidental cavities, they either form a complete envelope, such 
as naturally exists in the larynx, or in the Eustachian tube ; 
or else they appear as scattered grains, dispersed up and down 
on the surface, or in the substance of the surrounding cellular, 
fibrous, or other tissues. These cartilaginous grains, of irregu- 
lar form, and various sizes, bear a considerable resemblance 
in their texture, situation, and appearance, to the small de- 
tached spots which, in the minute bronchial divisions, succeed 
to the cartilaginous rings of the larger bronchi. Accidental 
cartilages may also assume the form of membranes when de- 
veloped between membranous tissues ; as, for instance, when 
they are formed under serous membranes, or between the 
coats of an artery. 

Accidental cartilages may be divided, with reference to their 
texture, into three classes. Those of the first class partake of 
the nature both of the fibrous and of the cartilaginous tis- 
sues ; thus representing the natural fibro-cartilages. In some 
cases the fibrous tissue predominates ; thus, I have seen it ar- 
arranged in concentric or parallel layers, between which the 
cartilaginous tissue was, as it were, deposited. In other cases, 
again, the texture becomes more homogeneous ; the cartilage 
then becomes the predominant part, and only a few traces of 
fibrous tissue can be observed, which may occur either on the 
surface of the cartilaginous mass, in its centre, or dispersed 
through its substance. 

Accidental fibro-cartilage has been observed, 1. in false ar- 
ticulations ; 2. at the extremity of the bones which had been 
long amputated ; 3. in the place of the ligaments belonging to 
ankylosed joints ; 4. in cicatrices of the skin, and of some pa- 
renchymatous organs ; 5. in the compound tumour of the 
thyroid, the ovaries, and the uterus ; 6. and lastly, in serous 
cavities where it is found in the form of isolated masses. Be- 
clard saw a tumour of this description, of the size of a wal- 
nut, contained in the cavity of the peritoneum ; its interior 



LESIONS OF NUTRITION. 217 

was fibrous, and it was as soft as intervertebral ligament to- 
wards its centre, which contained a small bone about the size 
of a pea. 

We should also observe, that the natural fibrous tissue pre- 
sents in some parts a remarkable disposition to be converted 
into cartilage : for instance, that portion of the tendon of the 
peroneus longus which rubs against the bones, is almost con- 
stantly transformed, in advanced age, into cartilage ; and, in 
many animals, the fibrous tissue of the sclerotica is replaced 
in several points by cartilaginous tissue. 

The accidental cartilages belonging to the second class pre- 
sent no appearance of fibres : they do not, however, altogether 
resemble the natural cartilaginous tissue as it is found in the 
adult ; but rather present a stronger analogy to the structure 
of that tissue as it exists in the foetus before its developement 
is fully completed. This second class, may, with propriety, be 
termed imperfect cartilages, or semi-cartilages. They possess 
a considerable degree of softness and flexibility, their consist- 
ence being sometimes no greater than that of the white of an 
egg boiled. Their colour is either a dingy yellowish white, a 
milk white, or a brilliant pearly-grey. Depositions of osseous 
matter are very often formed in this tissue, without its previ- 
ously having acquired a greater degree of consistence than 
before. Laennec has remarked, that the yellow variety is 
most prone to ossification. 

Imperfect cartilaginous tissue has been observed, 1. in the 
form of incrustations, or irregular patches, in the coats of ar- 
teries ; 2. in the form of cysts, in certain parenchymatous or- 
gans ; 3. in these organs likewise, as amorphous masses, either 
existing singly, or in combination with other morbid produc- 
tions ; 4. in the interior of certain articulations. Laennec 
states, that he has found in the shoulder and knee joints, semi- 
cartilaginous bodies, some round and others flat like ribands. 
They were unattached, and floated loose in the joints. He 
likewise found some of these bodies attached by their whole 
surface to the synovial membrane of the same joint in which 
others were floating loose ; but he was not able to ascertain 

Vol. I. 29 



218 LESIONS OF NUTRITION. 

satisfactorily whether they existed on the internal or external 
surface of the membrane. 

The accidental cartilages which we range in the third class, 
are those whose texture is perfectly analogous to that of the 
natural cartilages. They are of a beautiful silvery white colour, 
or like mother of pearl, or tinged with a slight shade of blue ; 
are perfectly homogenous in their structure, and cannot be 
divided into laminae or fibres, neither do they contain any ca- 
nals, cells, or areolae. They also possess a remarkable degree 
of elasticity. Like the natural cartilages they never present 
any traces of vascularity, unless when they are converted into 
bone.* 



ARTICLE VI. 

Osseous Transformation. 

This species might, with more propriety, be denominated 
the ossiform transformation, for it very seldom happens that the 
newly formed tissue exactly resembles the osseous tissue of 
the natural state : it is true, that it presents the same colour 
and consistence ; its chemical composition too, though not ex- 
actly identical, approaches very nearly to that of bone, but 
its form is rarely that of the natural bones, and its texture is 
still more dissimilar. 

The osseous transformation is almost exclusively confined to 
three tissues ; the cellular, the fibrous, and the cartilaginous. 
This fact, which is established by observation, is in perfect 
accordance with the laws of transformation already laid down. 



* Comparative anatomy proves, however, that cartilages may be vascular 
without possessing any tendency to ossification. Vessels of considerable size 
are found in several parts of the cartilaginous tissue of chondropterygious fishes, 
although their skeleton, as is well known, never becomes ossified. 



LESIONS OF NUTRITION. 219 

Wherever a solution of continuity occurs in the osseous tis- 
sue, the breach is repaired by a new production of osseous 
matter, which at first assumes no regularly defined shape, but 
afterwards becomes gradually assimilated in form to the por- 
tion of bone which it serves to replace. The numerous and 
interesting researches which have been made on this subject, 
shall be detailed hereafter. For the present, I shall only ob- 
serve, that, whenever a bone repairs the loss of substance it 
has suffered, the reparation invariably takes place at the ex- 
pense of fibrous or cellular tissue. I may also remark, that, 
whenever nature commences her operations for the purpose 
of repairing a fractured bone, there is at the commencement 
of the process an exuberance (if I may use the expression) in 
the production of the new osseous matter. It is deposited in 
all the parts surrounding the fractured point, and thus the 
neighbouring cellular tissue, the tendons, and the aponeuroses, 
become incrusted with phosphate of lime : these depositions 
subsequently disappear, and the ossific deposit is confined with- 
in the limits which the bone should naturally occupy ; and at 
the same time that the new bone is thus circumscribed in its 
limits, it likewise assumes the form and structure of the origin- 
al bone. 

I shall now proceed to consider ossification as it occurs in 
each of the three tissues to whicto; as I have already stated, 
this process is almost exclusively confined ; at least I have 
never been able to learn a single fact that could prove to 
my satisfaction the ossification of any of the other tissues. 



1. Ossification of the Cellular Tissue. 

All parts of the cellular tissue are not equally susceptible 
of this species of transformation. I have never met with an 
instance of ossification of the submucous cellular tissue. 
Baillie mentions a case in which the mucous membrane of the 
stomach was transformed into bone ; in this case, it is highly 
probable that the submucous tissue was the seat of the dis- 
ease ; but the description given by Baillie is so short, and at 



220 LESIONS OP NUTRITION. 

the same time so vague, that no conclusion can be drawn from 
it, either as to the precise situation of the ossification, or even 
as to the reality of its existence. The mucous membrane of 
the gall bladder has, in several well authenticated cases, been 
found invested with an ossiform layer, forming so complete an 
envelope as to convert the part into an unyielding, inflexible 
pouch ; but, in this instance, the submucous cellular tissue in 
which this osseous layer was formed, was likewise in contact 
with a serous membrane, and we shall presently see, that the 
subserous is one of the divisions of the cellular tissue in which 
osseous matter is the most frequently deposited. 

It will, I think, be found, that all those cases cf ossification 
which were long considered as the result of an osseous trans- 
formation of the serous membrane itself, are in reality seated 
in its subjacent cellular tissue ; at least, in all the cases of this 
description which I have examined, I have constantly found 
those concretions presenting a smooth pale surface on their 
serous side, from which I inferred that the serous membrane 
still existed over the surface of the ossification. 

The subserous cellular tissue generally undergoes some other 
modifications of nutrition before it is converted into bone. At 
first we observe an alteration in its transparency, and a whitish 
spot is formed, accompanied with some degree of thickening of 
the part ; sometimes it appears as if a turbid fluid were infil- 
trated into the areola? of the cellular tissue, which itself ap- 
pears to remain unaltered ; thus rendering it probable that a 
vitiated secretion was the first step of the morbid process. 
The appearance of the part then gradually changes, cartilagi- 
nous tissue is formed, and in it several osseous points are sub- 
sequently developed. Such is, in the generality of cases, the 
process by which ossification of the subserous cellular tissue 
is accomplished ; but, if I am not mistaken, there are also 
some cases in which the deposition of matter takes place all 
at once, without any antecedent alteration in the structure of 
the parts. 

The ossifications of the subserous cellular tissue generally 
occur in the form of minute granular bodies, or else of patches 
of various shapes and sizes. Their thickness is sometimes 



LESIONS OF NUTRITION. 221 

considerable, in which case they compress, and, as their size 
increases, reduce to atrophy the tissue of the organ with which 
they are in contact ; in this way, the spleen is sometimes great- 
ly reduced below its natural dimensions. There is no portion 
of the serous membranes under which these ossifications have 
not been found. In the skull, and the spinal canal, they have 
been observed disseminated through the cellular tissue which 
lines the arachnoid in both these cavities ; and I have occasion- 
ally found them on the convex surface of the cerebral hemis- 
pheres, presenting a striking resemblance to splinters of bone, 
for which they might, indeed, have readily been mistaken, if 
their situation under the arachnoid, and their connexion with 
the pia mater, did not prevent the possibility of such a mis- 
take. In the thorax, these incrustations are found lining the 
internal surface of the ribs, or investing the lungs, or heart. 
In the abdomen, they are never seen on the surface of any 
portion of the alimentary canal ; but are frequently found on 
the spleen, the liver, and the inferior surface of the diaphragm. 
They sometimes invest the tunica vaginalis, and lastly, they 
have been observed in the sacs of old hernias. 

The cellular tissue situated between the internal and the 
middle coats of the arteries, is even still more subject to os- 
sification than the subserous cellular tissue. This subject shall 
be more fully discussed with the other diseases of the circula- 
tory apparatus, in the 2d volume. 

The intermuscular cellular tissue has occasionally been found 
ossified in several points. Those cases in which it has been 
stated that the muscles themselves have been seen transformed 
into a bony substance, belong in all probability to this class, the 
ossification of the intermuscular tissue being accompanied with 
the atrophy and absortion of the true muscular texture. I 
have seen a remarkable instance of ossification of the cellular 
tissue interposed between the layers of muscle, in a limb af- 
fected with elephantiasis. The muscles were perfectly colour- 
less, and could with difficulty be discovered amidst the masses 
of thickened and indurated cellular tissue, to which the in- 
creased bulk of the limb was principally owing. Spiculae of 
osseous matter were dispersed in rows through the whole 



222 LESIONS OF NUTRITION. 

mass, and appeared to follow the intervals between the mus- 
cles; some of them joined the osseous vegetations which 
sprung up from the surface of the periosteum. 

In the cellular tissue is likewise formed the osseous capsule 
sometimes found in the back part of the eye, in certain cases 
of blindness ; and which was long considered as ossification of 
the retina. I am convinced, from a minute examination of 
several of these cases, that the retina itself is never transformed 
into bone ; for, I have found it in front of the osseous capsule, 
presenting its usual grey colour ; and, behind the capsule the 
choroid ; consequently, the osseous matter must necessarily 
have been deposited in the cellular tissue between these two 
membranes. 

To conclude, wherever an accidental cavity, or a preter- 
natural passage, has been formed, the cellular tissue of which 
their parietes are composed may become incrusted with de- 
positions of osseous matter, either in the form of isolated 
grains, or of small plates. Sometimes they even form a layer 
round the entire circumference of the parietes of the cavity. 
In this way we find tubercles and hydatids surrounded with 
an osseous envelope ; as also spiculae of bone in the parietes 
of fistulous passages. I once, on opening the body of a dog, 
which had been killed for the purpose of making some physio- 
logical experiments, found in the abdomen, on one side of the 
vertebral column near the kidneys, an osseous cyst, containing 
in its interior half a dozen grains of lead. 



II. Ossification of the Fibrous and Cartilaginous Tissues. 

If we trace the formation of the human skeleton, from the 
earliest period of its developement in the foetus, to extreme 
old age, we shall find the fibrous, and still more, the carti- 
laginous tissues, presenting a constant tendency to ossification. 
It is by the transformation of cartilage into bone, that a great 
part of the skeleton is formed in the foetus. After birth, we 
may observe the same process in operation, producing the ob- 
literation of the fontanelles, the completion of the sutures, and 



LESIONS OF NUTRITION. 223 

the union of the epiphyses, &c. During the age of maturity, 
the formation of osseous matter continues, but is confined to 
those parts where bone already exists ; hence it is, that the 
bones of the adult are constantly augmenting in substance. 
Lastly, in old age, ossification acquires a new disposition to 
seize on other parts of the fibrous and cartilaginous tissues ; 
and thus, the same process which begins with the individual 
when his existence first commences, seems to acquire a fresh 
degree of activity when that existence approaches its final ter- 
mination. Ai this period, the fibrous tissue of the sutures re- 
signs its place to the osseous tissue, and thus the sutures be- 
come obliterated ; the cartilages of the ribs, larynx, trachea, 
and bronchi, are successively converted into bone ; the bones 
of the pubis become united by the ossification of their inter- 
mediate cartilage, just as happened in the foetus with the two 
inferior maxillary bones ; and lastly, there is a remarkable 
tendency to the formation of calcareous depositions in every 
part of the arterial system, which, be it observed, contains a 
much greater proportion of fibrous tissue than is to be found 
in the venous system. Thus, then, we find that the process of 
ossification naturally increases in extent as the individual ad- 
vances in life : but, notwithstanding the general physiological 
nature of this process, it may constitute a true pathological 
condition, by interfering with the due accomplishment of any 
vital function, as in certain cases of ossification of the heart 
and arteries. 

When the ossification of the fibrous or cartilaginous tissue 
takes place at a premature period, or in parts where it does 
not usually occur in the progress of life, it ceases to be a 
physiological phenomenon, and must be considered as the re- 
sult of a morbid action. 

A state of active hypersemia generally precedes the osseous 
transformation of the fibrous, cartilaginous, and fibro-cartilagi- 
nous tissues. M. Rayer observed, that when he excited an 
artificial irritation in the fibro-cartilage of a rabbit's ear, the 
part was at first softened, a yellow matter was next deposited 
in its texture, and, finally, a calcareous deposit was formed, 
and a true ossification produced. M. Cruveilhier likewise ob- 



224 LESIONS OF NUTRITION. 

served different portions of periosteum, ligaments, and carti- 
lages, pass into the osseous or ossiform state, under the influ- 
ence of different stimulating applications. He also ascertained, 
by fracturing the limbs of animals, that the fibrous tissues 
around the fracture were frequently converted into bone. In 
many cases of fractures occurring in the neighbourhood of 
joints, the ligaments of the articulation have been found ossified. 
Fractures of the patella are frequently followed by ossification 
of the adjacent fibrous tissues. It has been observed, that in 
phthisical patients the cartilages of the ribs, and of the larynx, 
are prematurely ossified ; and I have myself remarked the 
ossification of the cartilages of the nasal fossa? and of the sur- 
rounding periosteum, in glandered horses. It is now perfectly 
ascertained, that some exostoses have in reality no connexion 
with the bone from whose surface they shoot up ; but are 
formed exclusively at the expense of the periosteum, which, 
after an attack of chronic irritation, attended with pain and 
tumefaction, is eventually converted into bone. Fractured 
cartilages are in general re-united by a hoop of osseous mat- 
ter, which is formed at the expense of the perichondrium. In 
some individuals attacked with caries of the vertebrae, the 
anterior vertebral ligament, and even the intervertebral fibro- 
cartilages, have been found in a state of ossification. When- 
ever a tendon rubs against a hard part, an osseous point is 
developed in that part of the tendon where the friction takes 
place. 

In all these instances we find the ossification of the fibrous 
and cartilaginous tissues evidently succeeding the irritation, or 
increased vascular action of the part; but in a variety of other 
cases, no morbid action whatever can be discovered previously 
to the deposition of osseous matter. How often, for example, 
do we find these depositions in the middle coat of arteries, in 
the fibrous tissue situated at the different orifices of the heart, 
in the dura mater, the pericardium, the capsule of the spleen, 
&c. without our ever having had the slightest evidence of the 
existence of any antecedent irritation of the part, either from 
the examination of symptoms during life, or of the morbid 
appearances found after death. No doubt, it may be argued 



LESIONS OF NUTRITION. 225 

that the irritation might have existed in a latent form ; but 
before I can adopt such an hypothesis, it must first be clearly 
and satisfactorily proved that this irritation is an essential 
element in the production of ossification ; in which case I 
must of necessity admit its existence, for then, the effect being 
produced, its cause must have existed either in a manifest or 
latent form. In my opinion, however, we have no more 
grounds for admitting an increase of vitality as the cause of 
the osseous, than of the fibrous or cartilaginous transformation. 
We learn from observation that the nutrition of the part is 
perverted, and altered from its natural type, but neither theory 
nor observation shews any necessary connexion between this 
alteration and the exaltation of the vascular action of the part. 

Ossifications may be considered with reference to their 
form, their texture, and their chemical composition. We shall 
now proceed to examine how far the accidental bones agree 
with the natural in these respects, and we shall find that the 
number of cases is very small indeed in which a perfect analogy 
can be established between them. 

The principal varieties of form which morbid ossifications 
present, are the following. 

1. Graniform ossification. Osseous granules are found, 
either isolated or in clusters, in the cellular tissue which lines 
the different membranes, as well as in that which enters into 
the composition of the parenchymatous organs ; they have 
also been found floating loose in some serous cavities. Their 
origin, in this latter situation, is in all probability the same as 
that of the cartilaginous bodies which are found in the joints 
and in the peritoneum. (See the preceding article on carti- 
laginous transformation.) The number of these granular 
bodies is exceedingly variable : I once found in a woman 
forty-seven years of age, who died of encysted dropsy of the 
ovary, the entire surface of one lung studded with a prodi- 
gious number of minute ossiform grains ; they were developed 
between the pleura, which they elevated, and the pulmonary 
parenchyma. In another individual, I found in the pia mater, 
on the anterior part of the right hemisphere of the brain, close 
to the median fissure, an osseous granule about the size of a 

Vol. I. 30 



226 LESIONS OF NUTRITION. 

pea, causing a corresponding depression in the cerebral sub- 
stance : this tumour did not produce any appreciable symptom 
during the life of the person. In the ovary of a middle aged 
woman, who died of phthisis, I found half a dozen white polish- 
ed grains, of the same consistence as bone, and about the size 
of peas ; in the centre of two or three of them was a small 
cavity filled with a few drops of a clear colourless fluid. It 
appeared to me highly probable that these granular ossifica- 
tions were formed of so many ovarian vesicles transformed 
into bone. In a little girl Of three years of age, who died in 
the Hospital des Enfans, under the care of M. Jadelot, the 
centre of the right lobe of the cerebellum was occupied by a 
dozen small bodies of an irregularly rounded form, and exactly 
similar in all their physical properties, to so many fragments 
of bone. They were imbedded in the substance of the cere- 
bellum, which appeared perfectly healthy all round them. 

The size of these granular ossifications is in general but 
small ; they very seldom exceed the dimensions of a large pea, 
and are frequently less than the head of a small pin. Their 
form may be more or less perfectly round ; their surface is 
sometimes smooth and pale ; in other instances it is uneven 
and rugged. 

2. Lamelliform ossification. The accidental osseous tissue 
which assumes this form is arranged in laminae, or irregular 
plates, on the adherent surface of the different membranous 
tissues. Patches of this description are found in the cellular 
tissue subjacent to the arachnoid in the skull and spine ; they 
are likewise found on the outer surface of the pleura, the peri- 
cardium, and the peritoneum, and between the middle and the 
internal coats of arteries. Their colour is generally of a dull 
white, sometimes inclining to a yellowish cast ; their size is 
very variable. They are sometimes so large as to line an en- 
tire side of the thorax with one continuous incrustation. An 
inflexible plate of bone is sometimes found occupying the place 
of the falx cerebri. I have myself found, on one occasion, a 
similar plate interposed between the lobes of the cerebellum 
and the posterior lobes of the cerebrum. The osseous tissue 
which is sometimes accidentally formed between the choroid 



LESIONS OF NUTRITION. 227 

and retina, is an exact representation both in form and size of 
the latter membrane. 

3. Membraniform ossification. I apply this denomination to 
that species of accidental osseous tissue, which follows the or- 
dinary arrangement of membranes, and constitutes the parie- 
tes of various cavities, of which I have already given some 
examples. I once found a hard body occupying the place of 
the thyroid gland, whose size it nearly equalled. This body 
consisted of a true osseous envelope, composed of distinct 
fibres mutually interwoven : its internal surface was uneven 
and corrugated, and it contained a cavity which was traversed 
by a number of very delicate .filaments, similar to those of the 
spongy part of the natural bones. They were attached at both 
extremities to the general osseous envelope, and between them 
was deposited a small quantity of reddish fluid of the consist- 
ence of syrup. 

4. Amorphous ossification. To this class should be referred 
those osseous masses which are often found by themselves, or 
in combination with other accidental productions, in the dif- 
ferent parenchymatous organs, especially in the ovaries and 
uterus. In these cases, however, the morbid alteration con- 
sists rather in the deposition of one of the elementary ingre- 
dients of bone, the phosphate of lime, than in a true osseous 
transformation ; they will therefore with propriety be consid- 
ered when we come to speak of the alterations of secretion. 

The texture of the accidental osseous tissue presents the fol- 
lowing varieties. 

1. It may present a homogeneous mass, without any appear- 
ance of fibres, or division into compact and spongy texture. 
The consistence of these masses is in some cases less than that 
of the natural bones ; in other cases it is the same ; and, lastly, 
in some instances it is much more considerable, so that, the 
greatest difficulty is experienced in breaking or sawing them 
asunder. When treated with acids they are in many cases 
perfectly dissolved. In fact they only resemble the natural 
bones in colour, consistence, and the presence of certain cal- 
careous salts. 

2. Instead of the homogeneous mass above described, we 



228 



LESIONS OF NUTRITION. 



sometimes find, in the osseous deposit, certain arrangements 
of structure which approximate more or less to those of the 
natural bones. For instance, several of the plates or bony- 
patches already described, present a perfect identity of struc- 
ture with the compact osseous substance which is found in the 
flat bones of the skull, where the diploe is wanting ; and they 
sometimes exhibit an appearance of fibres regularly radiated, 
or irregularly interlaced, just as in the flat bones of fishes. 
There are some of these osseous laminae which bear the 
strongest resemblance both in form and texture to the os un- 
guis. An appearance of the spongy or reticulated structure is 
in some cases found combined with the compact solid texture. 
These cases comprehend all the analogies of texture which can 
be established between the natural and accidental osseous tis- 
sues ; the only instance in which the newly formed tissue 
represents exactty the texture of the natural bone, is that in 
which the periosteum, or the medullary membrane, is trans- 
formed into a new bone, in order to replace a portion of bone 
which had been destroyed ; and even in this case, the approxi- 
mation of structure takes place but gradually ; thus, in the long 
bones, when newly formed, there is at first no medullary cavity. 
Chemical analysis establishes in the accidental, as well as in 
the natural bones, the presence of two salts, namely r , the phos- 
phate and the carbonate of lime, and of an animal matter of 
the nature of gelatine. In the natural bones, however, these 
substances, combined with others which have not as yet been 
discovered in the accidental osseous tissues, are invariably 
found together, and in the same proportions, some allowance 
being of course made for the difference of age, sex, idiosyn- 
crasy, and disease ; whereas in the accidental bones these sub- 
stances may exist either singly or in combination, and, when 
combined, nothing can be more variable than their relative 
proportions. Thus the calcareous salts are sometimes found 
without the combination of any animal matter ; at other times 
they are united with a small proportion ; and, again, in other 
instances, this matter forms the predominant ingredient. I 
recollect, on one occasion, immersing a cyst with osseous 
parietes into sulphuric acid, and finding it thereby transformed 
into a cartilaginous cyst. 



SECTION III. 



LESIONS OF SECRETION. 



The blood which circulates through an organ may be sub- 
mitted to three species of elaboration. By the first, it is de- 
prived of a series of molecules, which, being acted on by the 
plastic force that regulates the formation of each individual 
tissue, are appropriated to the organ itself, become an integral 
part of its structure, and thus repair the losses which it is con- 
stantly sustaining. This constitutes the process of nutrition, 
properly so called. By the second species of elaboration, an 
albuminous matter, in the state of liquid or of vapour, is con- 
stantly produced in every part of the system. This species of 
secretion appears to be no less essential to the maintenance of 
life, than the nutritive secretion itself. Its existence is most 
evident, 1. in the areolae of the cellular tissue ; 2. in the serous 
cavities, which may be compared to so many cellular areolae 
magnified ; 3. on the surface of the tegumentary membranes, 
where it should be distinguished from the mucous and seba- 
ceous secretions ; 4. on the internal surface of the vascular 
system. From this enumeration it appears, that wherever an 
organ presents a surface, there this secretion or transpiration 
takes place. There can no doubt be entertained that this per- 
spirable matter is furnished directly by the blood ; for, the 
presence of different substances may be detected in it, at a 
very short interval after they have been mixed with that fluid. 
If, for example, some prussiate of potash be injected into the 



230 LESIONS OF SECRETION. 

veins of a living animal, its presence in the fluid of the serous 
membranes may almost immediately be detected by the sul- 
phate of iron. Camphor, or phosphorated oil, when mixed 
with the blood, may with equal facility be recognized in the 
pulmonary vapour which escapes at each expiration. I have 
thought it necessary to allude to these physiological facts, be- 
cause it is of the utmost importance, in a pathological point of 
view, to have a clear conception of the origin of this perspira- 
ble matter, the alteration of which appears to play a very im- 
portant part in causing several accidental productions. Lastly, 
the third species of elaboration which the blood undergoes, by 
far less general than either of the preceding, takes place, at 
least in the natural state, only in certain organs of a particular 
organization, which present various degrees of complication of 
structure, from that of a simple follicle, to that of the liver. 

In the preceding section, I have attempted to describe the 
different organic lesions which result from a morbid modifica- 
tion of the first of these three species of elaboration. The 
reader will, I trust, recollect, that in all these lesions we could 
discern only various alterations in the nutrition of the tissues 
affected, or, in other words, alterations in the quantity or qual- 
ity of the molecules of which these tissues were composed. 
It now remains for us to consider the morbid modifications of 
the other two species of elaboration which the blood undergoes. 
These constitute a very numerous class of diseases ; for, in 
whatever part of the body we find any productions, whether 
solid, liquid, or gaseous, which have nothing analogous to them 
existing naturally in the system, it is impossible to conceive 
their formation in any other way than by supposing them the 
product of some organic action, more or less analogous to that 
which, in the healthy state, separates from the blood the mate- 
rials for repairing the several tissues, or forming the different 
secretions. This mode of accounting for the formation of the 
different accidental productions, is not without some practical 
utility ; for, a priori, it leads us to suppose, that the same con- 
ditions which, in the healthy state, exert an indisputable influ- 
ence over the secretions, should likewise influence the forma- 
tion of accidental productions, if these productions be in reality 



LESIONS OF SECRETION. 231 

only morbid secretions. Now, in the healthy state, the secre- 
tions are influenced, 1. by the quality of the blood, as is proved 
by the modifications which may be produced in the bile, the 
urine, the milk, &c, by altering the composition of that fluid ; 
2. by the condition of the secretory organ ; 3. by the state of 
innervation : the fact must be familiar to every one, that any 
slight derangement in the functions of the nervous system ma- 
terially affects the secretion of the tears, of mucus, bile, milk, 
sweat, urine, and saliva. In the same manner, the different 
morbid secretions may be materially influenced, 1. by the state 
of the blood ; 2. by the condition of the solids where the se- 
cretion takes place ; and 3. by the nervous system. 

In order to study with more accuracy the different morbid 
secretions, I shall divide them into three principal classes. 

In the first, shall be placed those morbid secretions which 
retain the qualities of the natural secretions, but are much 
more abundant in quantity than usual. These secretions some- 
times remain in the cavities where they have been formed, 
constituting the different varieties of effusion : in other cases, 
they are eliminated from the system, as fast as they are formed ; 
hence arise the various species of Jlux. 

In the second class, the qualities of the natural secretions are 
likewise retained ; but they, or some of their elements, are 
found in a part of the body different from that in which they 
are generally formed or deposited : they may either have been 
actually formed in this new situation, or may have been trans- 
lated thither by different ways. 

The third class comprehends those classes in which, in place 
of the natural secretion, other products are formed, which 
sometimes appear to be merely modifications of the natural 
secretion, or at least bear some resemblance to it ; and, in 
other instances, bear no resemblance whatever to it, and seem 
to be perfectly novel productions. These morbid secretions 
may be developed in any part of the body ; for, the only con- 
dition requisite for tneir formation, is the power of secreting, 
which, as we have already seen, is possessed by every tissue 
in the body. These products of morbid secretion may be per- 
fectly identical, though furnished by the most different tissues ; 



232 LESIONS OF SECRETION. 

for, wherever they occur, they seem to depend principally on 
some modification of the perspirable matter, which is exhaled 
in the form of fluid or of vapour by every tissue, and is ap- 
parently identical in them all. Even the blood itself, when 
organized, acquires the faculty of secreting; for, throughout 
all animated nature, the first of these facts (organization) ne- 
cessarily infers the second (secretion). Hence it appears, that, 
in the blood, while in its fluid state, as it circulates through the 
vessels of the living animal, the materials of different morbid 
secretions may be formed, and, in the blood, when coagulated, 
these morbid secretions themselves may be developed. 

In a fourth and last class, I shall describe the morbid gaseous 
secretions ; which in their history and etiology, have some re- 
semblance to the morbid productions of the preceding class, 
but yet differ from them so much in many particulars, as to 
render it necessary to set apart a distinct chapter for their con- 
sideration. 



CHAPTER I. 

Modifications in the Quantity of the Secretions. 

The quantity of the secretions may be either increased or 
diminished ; hence this class of morbid alterations may be di- 
vided into two species ; the first consisting in an increase in 
the quantity of the secretions Qiypercrinid) ; the second, in 
their diminution of quantity or total suspension (acrinia). 

I shall at present treat only of the first of these species, be- 
ing compelled to pass the second over in silence, for want of 
sufficient data to illustrate its causes and effects. I may, how- 
ever, remark, that one of the first effects of irritation, is to 
produce in the affected organ a suspension of the secretory 
process ; at a subsequent period the secretion is re-established, 
but is almost constantly either increased in quantity, or altered 



LESIONS OF SECRETION. 233 

in quality, I have more than once had occasion to observe, 
in my dissections of individuals who, during their illness pre- 
sented different nervous symptoms, such as delirium, convul- 
sive motions, &c. that the only appreciable lesion to be de- 
tected in the encephalic organs was a remarkable dryness of 
the membranes, which certainly was not their natural state. 
The secretions may likewise be suddenly suspended by cer- 
tain modifications of the nervous influence. For instance, the 
bile often ceases to flow into the intestines, and the tongue 
becomes suddenly parched, in consequence of a strong mental 
impression ; and, in typhoid diseases, the secretion of urine is 
often totally suspended. 



ARTICLE I. 

Hypercrinia with Retention of the Secretion. 

When a fluid is separated from the blood in a greater quan- 
tity than usual, it may either be retained in the cavity where 
it is formed, or may make its escape externally. 

In order that the first species of hypercrinia may take place, 
it is necessary that the cavity where the secretion is formed 
should be close at all points, or, at least that it present no outlet 
whereby the effused fluid may make its escape. The only 
parts which present these conditions are, the adipose and cel- 
lular tissues, and the serous membranes ; and in these parts 
exclusively can those collections of fluid be formed, which are 
designated by the generic appellation of dropsy. I am aware 
that cases of dropsy of the mucous membranes have been re- 
corded by Nosologists ; but they can only take place when 
the communication of these membranes with the exterior is 
accidentally closed. Thus, in those cases which have been de- 
scribed as dropsy of the stomach, the pyloric orifice, being near- 
ly closed, with difficulty admits the passage of a small propor- 
Vol. I. 31 



234 LESIONS OF SECRETION. 

tion of the substances which have been swallowed ; conse- 
quently these, when mixed with the products of the gastric se- 
cretion, form a prodigious accumulation in this organ. In like 
manner, the name of dropsy in the uterus has been applied to 
those cases in which an unusual quantity of fluid is formed in 
its cavity, at the same time that the narrow orifice of the os 
tincse does not allow it to escape. I once saw the gall bladder 
form a considerable tumour below the cartilaginous margin of 
the ribs, in consequence of the obliteration of its duct : instead 
of bile, its cavity, which was enormously dilated, contained a 
large quantity of clear serous fluid. This case, however, is 
far from common ; for, in general, when a reservoir ceases 
for a considerable time to receive the fluid which should 
be deposited in it, all secretion there gradually ceases, its cav- 
ity becomes obliterated, and the texture of the viscus is some- 
times even resolved into simple cellular tissue. 

There is no part of the cellular tissue which may not be- 
come the seat of serous collections to a greater or less extent. 
They in general occur most frequently in those parts where 
its texture is loosest, and its position the most dependent. 
The dense compact cellular tissue which lines the mucous 
membranes, is not exempt from this affection, notwithstanding 
Bichat's opinion to the contrary. In such cases, the mem- 
branes, being raised by the accumulation of serum behind 
them, present a tremulous appearance, and sometimes even 
convey a distinct sense of fluctuation. The peritoneum is, of 
all the serous membranes, that which is most frequently affected 
with dropsy. I shall presently have occasion to enumerate 
some of the causes of this tendency to ascites. 

The fluid which is found in the serous membranes investing 
the brain and spinal cord, should not be considered a morbid 
production ; it is, in fact, a healthy secretion destined to fill 
the space which intervenes between these centres of the ner- 
vous system and the osseous parietes by which they are pro- 
tected. The existence of this fluid, first positively ascertained 
by Magendie in living animals, and in human subjects examin- 
ed at a short interval after death, might have been inferred 
from comparative anatomy. From this source we learn, that 



LESIONS or SECRETION. 235 

the capacity of the skull does not decrease exactly in the same 
proportion as the size of the brain ; and that when the cere- 
bral mass is very small, the cranial bones are not so exactly 
moulded to its surface, but that there remains between them 
and it a space filled with a serous or adipose fluid, the quantity 
of which is in the inverse ratio of the cerebral mass. Now, 
in man, whose spinal marrow is but little developed, in com- 
parison with his brain, or with the spinal marrow of other 
animals, there is a considerable space intervening between it 
and the parietes of its canal ; which space, we might from 
analogy have inferred, must also be filled by a fluid. This 
subject I shall fully resume when I come to treat of the dis- 
eases of the nervous system. 

Neither should we regard as a morbid production, the fluid 
which is almost invariably found in small quantities in the dif- 
ferent serous membranes, when the body is opened more than 
thirty hours after death. In the preceding case, the fluid ex- 
isted during life ; in the present instance, on the contrary, it is 
when the influence of the vital laws has completely ceased, 
and when the putrefactive process commences, that these 
membranes begin to present this phenomenon. In conse- 
quence of the diminution of cohesion at this period sustained, 
both by the blood, which no longer enjoys its vitality, and by 
the parietes of the blood-vessels, the molecules of which have 
lost their vital force of aggregation, the thinnest part of the 
sanguineous fluid, the serum, soaks through the solids with 
which it is in contact, and transudes into the different cavities 
of the body. If these cavities communicate with the external 
atmosphere, the effusion evaporates ; if no such communica- 
tion exists, the serum continues to accumulate, either pure or 
mixed with a certain proportion of colouring matter. Ac- 
cording to M. Gendrin, (Histoire Anatomique des Inflamma- 
tions,) a greater quantity of this effusion is in general found 
after death in the serous cavities of young persons, than in 
those of adults, and especially of old men. 

The fluid which is effused in superabundant quantity, into 
the serous membranes, or cellular tissue, presents almost all 
the physical properties of the serum of the blood. Like it, it 



236 LESIONS OP SECRETION. 

may be found either perfectly colourless, or of a green, yellow- 
ish, or reddish tint. All these varieties of colour seem to de- 
pend on the presence of a certain quantity of the colouring 
matter of the blood. In jaundice, the dropsical fluid contains 
a yellow colouring matter analogous to that of bile ; it has also 
in some cases been found to contain uric acid. Like the 
serum of blood, it does not coagulate spontaneously ; but may 
be, like it, coagulated by the application of heat, acids, alcohol, 
or electricity. The dropsical fluid is sometimes exactly anal- 
ogous in its chemical composition to the serum of blood, like 
it containing, on an average, in one thousand parts, nine hun- 
dred of water, eighty of albumen, and the rest of soda, various 
salts, and an animal matter resembling mucus. In other 
cases, this fluid contains less water, and a much greater pro- 
portion of albumen ; and in others again, it is the albumen 
which is deficient. When that is the case, it may vary in 
quantity, from twenty or twenty-four parts in a thousand, to a 
mere trace, the effused fluid being then almost wholly com- 
posed of pure water holding a few salts in solution. Under 
some peculiar circumstances, this fluid is found to contain, in 
addition to albumen, another animal substance, the precise 
nature of which has not yet been exactly ascertained, which 
gives it a turbid appearance. This substance, which has been 
denominated extracto-mucous, may either be arranged in the 
form of minute molecules, uniformly combined with the serous 
fluid, which thence acquires a slight opacity throughout ; or it 
may be disposed in filaments or flocculi floating in the midst of 
the fluid, which then has its transparency altered in those 
points only where these little flocculi exist. I do not think 
that this peculiar modification of the fluid of serous membranes 
has any necessary connexion with the irritation or inflamma- 
tion of these membranes ; for I have repeatedly found a slight- 
ly turbid fluid, or mixed with some flocculi, in the different 
serous cavities of individuals who had died of chronic diseases, 
and in whom neither the symptoms presented during life, nor 
the morbid appearances found on dissection, afforded the 
slightest proof of the existence of any recent or former attack 
of inflammatory action in the membranes lining those cavities. 



LESIONS OP SECRETION. 237 

From the preceding observation it appears, that the serous 
membranes ar e capable of producing three different modifica- 
tions of secretion, without themselves undergoing any altera- 
tion of texture, or presenting the slightest appearance of san- 
guineous congestion. 1. A portion of serum appears to escape 
from the blood, in the same state as it exists in that fluid. 2. 
A sort of choice or selection is made in the ingredients of 
which this fluid is composed, so that, according to the nature 
of the selection, some one of the elementary ingredients of the 
serum of the blood predominates in the composition of the 
effused fluid. 3. A new substance, to which the blood con- 
tains nothing analogous, is generated either in the effused fluid, 
or in the serous membrane from which the effusion proceeds. 

There are several kinds of causes which favour the accu- 
mulation of fluid in the different serous cavities, and in the 
areolae of the cellular tissue. The following enumeration 
comprises those which are most efficient in the production 
of dropsy. 1. A degree of stimulus or irritation of the organ 
where the dropsy is formed. 2. The sudden disappearance 
of another dropsy. 3. The suppression of certain secretions. 
4. Various alterations in the blood. 5. Obstacles to the 
venous circulation. 6. Lastly, dropsy is sometimes found ac- 
companying certain states of cachexia, in which none of the 
conditions above enumerated can be positively discovered, 
but in which they may nevertheless, with some probability, be 
supposed to exist. 



FIRST ORDER OF THE EXCITING CAUSES OF DROPSY. 

Stimulus or Irritation of the Serous Membranes, or of the 
Cellular Tissue. 

Such may have been the original source of the disease, and 
it may have subsequently disappeared, leaving behind it, as its 
effect, an accumulation of serous fluid. In this case, the dis- 
ease, which was at its commencement inflammatory, and 
should then have been treated as such, subsequently changes 



238 LESIONS OF SECRETION. 

its character ; and it then becomes necessary to employ a plan 
of treatment diametrically opposite to the anti-phlogistic, in 
order to dissipate the same dropsical effusion, which, at an 
earlier period, might have been removed by blood-letting. In 
other cases the irritation continues to the last, and then the 
treatment of the collection of fluid becomes only a secondary 
consideration. Again, in other cases, the irritation, after hav- 
ing disappeared for some time, returns again, and, what is par- 
ticularly remarkable, the re-appearance of the local irritation 
not unfrequently effects the cure of the dropsy which it had 
originally caused. 

The irritation which precedes the accumulation of a serous 
fluid, may either be seated in the same tissue in which the 
dropsy is formed, or may affect some of the adjacent tissues. 
For instance hydrocephalus, both in its acute and chronic 
form, is often consecutive to an irritation in the proper tissue 
of the brain: and ascites sometimes occurs after an attack of 
gastro-enteritis. The submucous cellular tissue frequently 
becomes infiltrated after an acute or chronic inflammation of 
the membrane to which it is subjacent ; in like manner, we 
constantly observe the formation of oedema in those portions 
of the subcutaneous cellular tissue which correspond to parts 
of the skin that have been irritated. Every person must be 
familiar with the serous infiltration which so frequently forms 
round old ulcers, or blisters when kept long open, or even un- 
der a simple sinapism, when applied to individuals worn down 
by protracted sufferings, or chronic disease. The induration 
of the cellular tissue of the extremities, which sometimes suc- 
ceeds to the chronic inflammation of the skin of these parts, 
often commences by a simple serous infiltration ; and when 
the induration subsequently disappears, the cellular tissue, be- 
fore returning to its natural state, is again found infiltrated 
with serum. 



LESIONS OP SECRETION. 239 



SECOND ORDER OF CAUSES. 

The Disappearance of another Dropsical Effusion. 

When the fluid which had been accumulated in a serous 
cavity, or in the cellular tissue, suddenly disappears, some of 
the following phenomena usually succeed. 1. Copious evac- 
uations are established from different secreting surfaces ; by 
which a great quantity of aqueous fluid is discharged from the 
system, and no injury sustained. 2. No such evacuations 
take place, and yet the general health is re-established. 3. At 
the same time that the effused fluid is absorbed, without any 
corresponding evacuation being established, various derange- 
ments of the principal functions take place : the most remark- 
able of these is the sudden modification which the nervous 
influence undergoes ; the patient experiences an extraordinary 
sense of oppression, and falls into a state of collapse, which 
not unfrequently proves fatal. Lastly, it sometimes happens, 
that the fluid which disappears from one cavity, almost imme- 
diately accumulates in another, where its presence is an- 
nounced by a new train of morbid symptoms. I shall never 
forget the case of a patient who was labouring under organic 
disease of the heart, and in whom the sudden disappearance 
of ascites was immediately followed by all the usual symptoms 
of a most violent attack of apoplexy, which proved quickly 
fatal. On opening the body, the following appearances were 
presented : the peritoneum did not contain a single drop of 
serum ; not the slightest vestige of haemorrhage was to be 
found in the brain, but the ventricles were all enormously dis- 
tended by a clear serous fluid, which existed in such prodi- 
gious quantities, that the roof of the lateral ventricles was con- 
siderably raised, and conveyed when touched, an evident 
sense of fluctuation. 

If we compare these facts with the phenomena produced by 
injecting water into the veins of animals, we shall find several 
points of analogy between them. If, before the water is in- 
jected, the animal has been copiously bled, a considerable 



240 LESIONS OF SECRETION. 

quantity may be introduced into its circulating system, with- 
out producing any serious or dangerous consequences. But, if 
the water be injected without previously taking the precaution 
of diminishing the mass of blood in circulation, the animals 
quickly evince symptoms of extreme suffering ; their brain 
becomes affected, and they fall into a state of immobility and 
prostration of strength. At the same time, their respiration is 
accelerated; and, if the injection be continued, the severity of 
the symptoms increases, and the subject of the experiment 
dies, either by the lungs, in a state of asphyxia, or by the 
brain, in a state of coma. On dissection, the lungs are found 
excessively congested with a serous fluid, and effusions more 
or less extensive are likewise found in different parts of the 
cellular tissue* and in the serous membranes. When I come 
to treat of fluxes I shall have occasion to revert to this sub- 
ject, and consider it more in detail. I have merely alluded to 
it here, in order to shew how, after the sudden disappearance 
of a dropsy, a new serous collection may be formed at the 
expense of the same fluid, which, being absorbed from the 
cavity where it was originally effused, re-enters the circula- 
tion, in order to be again effused on the surface of some other 
serous cavity. 



THIRD ORDER OF CAUSES. 

The Sup])ression of certain Secretions. 

It has been long remarked that dropsies are particularly 
prevalent in cold and damp climates ; and that diabetes is also 
a frequent affection in such countries. The researches of M. 
Edwards (Influence des Agens Physiques sur la Vie) have 
thrown considerable light on this subject : he has clearly 
proved, that, under the influence of a moist atmosphere, the 
perspiration which is constantly going on from the skin and 
mucous surface of the air-passages, is reduced to its minimum. 
May we not then reasonably suppose, that the serous fluid 
which the blood cannot throw off by these surfaces, is sep- 



LESIONS OF SECRETION. 241 

arated from it in the cellular tissue, the serous membranes, or 
in the renal parenchyma ? And may we not regard what oc- 
curs in this case, as the reverse of that which happens when 
the cutaneous transpiration attains its maximum, and a drop- 
sical effusion disappears at the same time that the skin is 
bathed in sweat ? I have elsewhere related a case, in which 
the disappearance of hydrothorax was attended with an ex- 
traordinary exhalation of serous fluid from the bronchial tubes ; 
and I really see no reason why the dropsical affections which 
so frequently occur during convalescence from scarlatina, may 
not depend on the diminution of the cutaneous perspiration, 
which continues during the whole period of the desquamation 
of the epidermis. 

One of the few instances of dropsy occurring without any 
appreciable organic cause, which I have had an opportunity 
of observing, was where that affection accompanied the ex- 
istence of only one kidney. (Clinique Medicale, vol. iii.) 
Was the aqueous fluid which in this case filled the cellular 
tissue and serous membranes, the same which ought to have 
been separated from the blood by the kidney which was 
wanting ? 



FOURTH ORDER OF CAUSES. 

Alterations of the Blood. 

Several of these alterations, though of diametrically op- 
posite characters, alike contribute to the production of a cer- 
tain numbed of dropsies. Thus, whether there be a superabun- 
dance of b}ood in the vascular system ; or whether that fluid 
be deficient in quantity, or in fibrine ; or so altered in quality 
as to facilitate the separation of its aqueous part ; the constant 
effect of all these alterations, is a dropsical effusion. 

It not unfrequently happens, that, in individuals in the 
flower of their age, and presenting all the signs of well marked 
general hyperemia, the cellular tissue of the extremities be- 
comes cedematous, and the serous cavities filled with fluid. 
Vol. I. 32 



242 LESIONS OF SECRETION. 

In these cases there is no evidence whatever of any inflam- 
matory action in the parts where those serous collections are 
formed ; neither can any symptom be discovered indicative 
of any organic affection ; all that the most attentive examina- 
tion can discover, is the co-existence of a state of general 
plethora with the dropsical effusions ; and it is only by dimin- 
ishing the mass of blood by low diet and copious bleedings, 
that these effusions can be effectually removed. I once had 
an opportunity of examining the body of an individual in 
whom the dropsy was thus evidently connected with a state 
of general plethora. The case I allude to was that of a man 
of about thirty years of age, who had been for a month labour- 
ing under anasarca and ascites, when he became a patient at 
La Charite. I repeatedly examined him with the most scru- 
pulous care, but could never detect the slightest symptom of 
any organic lesion ; he was full of life and vigour ; his eyes 
were habitually injected ; he had repeated attacks of epistaxis ; 
and his skin constantly presented a florid colour, which con- 
trasted strangely with the doughty state of the subcutaneous 
cellular tissue. The secretion of urine was not diminished ; 
the pulse was full and bounding, and rather quicker than nat- 
ural. A few days after his admission, and without any assign- 
able cause, he was suddenly seized with delirium, and shortly 
after fell into a state of coma, in which he died. On opening 
the body, we found a large quantity of clear colourless serum 
in the cellular tissue of the extremities, and in the peritoneum ; 
but neither the abdominal viscera, nor the peritoneum, present- 
ed the slightest trace of disease. There was in each cavity of 
the pleura about half a pint of fluid, and there was also a small 
quantity in the pericardium ; but there was no more appear- 
ance of morbid alteration in the thoracic viscera than in those 
of the abdomen. In the skull, the cellular tissue which lines 
the arachnoid, where it is reflected over the convex surface of 
the brain, was infiltrated with a quantity of serous fluid ; the 
different ventricles were also filled with it ; but neither in the 
membranes, nor in the substance of the brain, could we dis- 
cover any morbid appearance. It appears to me highly prob- 
able, that the timely employment of copious bleedings might 



LESIONS OF SECRETION. 



243 



have removed the dropsy in this case, and at the same time 
have prevented the fatal aud unexpected termination of the 
disease ; for there was no alteration discovered in the solids 
sufficient to account for either the dropsy, the symptoms which 
succeeded, or the death itself; so that it must have been a 
case of dropsy from plethora. As to the phenomena which 
ushered in the fatal termination, they were, doubtless, the con- 
sequence of the sudden extension of the effusion to the cere- 
bral cavities. 

The influence of a state of general hypersemia in producing 
certain dropsies, may be proved by the following experiment. 
If, in a living animal, we increase by artificial means the mass 
of fluid contained in the vascular system, and keep the vessels 
for some time in a state of over-distention, we thereby not only 
favour the formation of serous effusions, but likewise diminish 
the absorption of the fluids already effused into the cellular 
tissue : if, under such circumstances, we open a vein and al- 
low some of the circulating fluid to escape, the serous effusions 
soon disappear, and the absorption resumes its accustomed ac- 
tivity. 

From these, and many similar facts, it appears to me fully 
established, that many dropsies depend on a state of plethora, 
although it is not easy to determine how the effect is produced. 
I shall not take upon me to decide, whether the dropsy in such 
cases results from the mechanical transudation of the serous 
part of the blood through the panetes of its over-distended 
vessels, or from the diminished activity of the process of ab- 
sorption. 

A condition of the blood, altogether different from the pre- 
ceding, that in which there is a notable diminution in its quan- 
tity, and even a tendency to anaemia, may likewise produce 
dropsy. In this way the disease frequently follows too co- 
pious, or too often repeated venesections ; and in this way also 
are produced those dropsies which assume an almost epidemic 
form during seasons of great scarcity, when the population are 
deprived of their natural sustenance, and are reduced to live 
on the roots and herbs of the field. One of the first effects re- 
sulting from the use of such diet, must necessarily be, that the 



244 LESIONS OF SECRETION. 

qualities of the blood are modified, and it becomes impover- 
ished from the diminution of quantity of its fibrine. I have 
elsewhere (Clinique Medicate, torn, iii.) related some cases of 
persons dying dropsical, who presented no appreciable lesion 
of their solids, but in whom there was in reality no blood to be 
found, either in the large vessels or in the capillaries ; for the 
term blood could not, with propriety, be applied to the reddish 
watery fluid which the blood-vessels contained. In these in- 
stances, the connexion between the aqueous state of the blood 
and the formation of the dropsical effusions, was particularly 
striking. In all such cases, the slightest irritation of the skin 
is sufficient to produce an infiltration of the serous fluid into 
the subjacent cellular tissue. Not long since, I had an oppor- 
tunity of seeing the application of sinapisms to the thighs pro- 
duce this effect, in a case of acute peritonitis, which had been 
treated by copious and repeated venesections. Erysipelas is 
frequently accompanied with oedema in persons advanced in 
life, or whose constitutions are weakened by great losses of 
blood, or long abstinence from sufficiently nutritive diet. 

To conclude, dropsies, both partial and general, have been 
observed occurring very speedily after the application of cer- 
tain poisons, especially those of various reptiles. Now, on 
what part of the system but the blood can we suppose that 
the poison, in such cases, primarily acts ? The truth of this 
position might be established by physiology, even though the 
effects of such poisons on the blood were not proved to de- 
monstration by the alterations which the sensible qualities of 
that fluid invariably undergo. The most remarkable, and 
perhaps one of the most constant of these alterations is, that 
the blood loses altogether the power of coagulating : the effect 
of this is, that its serous part separates, and escapes with great 
facility from the vessels, either pure, or combined with a va- 
riable proportion of the colouring matter, and thus forms 
various dropsical effusions. Several points of analogy may 
be traced between these cases of poisoning by venomous 
animals, in which the dropsy is connected with a primary al- 
teration of the blood, and those typhoid fevers in which the 
introduction of some molecules of morbid animal matter into 



LESIONS OF SECRETION. 245 

the mass of blood, produces such an entire change in its prop- 
erties, that it escapes from its vessels, and is extravasated on 
every surface of the body. 



FIFTH ORDER OF CAUSES. 

Obstacles to the Venous Circulation. 

The obliteration of the principal vein of a limb, and of its 
chief collateral branches, so frequently co-exists with a drop- 
sical affection of the part, that it appears extremely probable 
the first of these alterations is the cause of the second.* There 
is no difficulty in comprehending how the obliteration of the 
collateral veins is essential to the production of this species of 
dropsy ; and the want of this essential condition explains why 
dropsies have not been found in parts which had their principal 
veins perfectly obstructed ; and also why the ligature of the 
femoral vein in dogs does not always produce dropsy of the ab- 
dominal extremity. We must not however attempt to conceal, 
that doubts may reasonably be entertained as to the correctness 
of this etiology of local dropsies, and that it may be urged, that 
what we take to be the cause of the accumulation of serum, 
may in reality have been its effect ; that the blood, being by 
some unknown cause deprived, in the capillary vessels, of its 
serous part, may have been rendered more prone to coagulate, 
and, in consequence, may have formed itself into a solid mass 
in the large veins, and thus obstructed their cavities. To 
these arguments it may be answered, that if the coagulation 
of the blood in the veins were merely the consequence of its 
being deprived of a portion of its serum, the coagulation should 
take place in the small as well as in the large veins ; whereas, 
in general, the small vessels are perfectly free and unobstruct- 
ed, clots of blood first make their appearance in the veins of 
more considerable calibre, and it is only in the principal ves- 



* This cause of local dropsy has lately received considerable elucidation 
from the scientific researches of M. Bouillaud. 



246 LESIONS OF SECRETION. 

sels that the coagula are so perfectly formed as to obstruct 
the passage altogether. Besides the pressure of a tumour on 
the principal vein of a limb is capable of producing a similar 
state of oedema ; and in this case it is evident that the obstruc- 
tion of the vein is the cause, and not the effect of the dropsy. 
An additional proof is furnished by the fact, that the extent of 
the dropsy corresponds exactly with the point in which the 
venous obstruction exists ; thus, the obliteration of the femoral 
vein is attended with oedema of the lower extremity, and that 
of the axillary vein, with oedema of the corresponding upper 
extremity. When the vena cava is obliterated, both lower 
extremities are infiltrated with serum ; but there is no effusion 
into the peritoneum, unless at an advanced period of the dis- 
ease, when it sometimes occurs as a consecutive affection. 
On the other hand, if it be in the vena portse that the circula- 
tion is obstructed, whether in its trunk or in its subdivisions in 
the liver, the dropsy invariably commences in the peritoneum. 
Lastly if the obstacle to the venous circulation exists in its cen- 
tral point, the heart, the effects of the obstruction should be 
felt in every point of the venous system, and consequently 
there should be a general tendency to the formation of drop- 
sical effusions in every part of the body ; which is precisely 
what occurs in organic affections of the heart. It has been 
stated, but, as I conceive, erroneously, that congestion of the 
spleen was a frequent cause of dropsy ; it is true that these 
affections do co-exist, but the cause of the dropsy really lies 
either in the liver, or some other part. I doubt likewise 
whether dropsy is ever produced by chronic affections of the 
lungs, even in those cases where a considerable portion of 
their parenchymatous substance is in a state of induration ; 
unless when they are combined with organic disease of the 
heart, or some other cause capable of producing dropsy. 

Are obstacles to the lymphatic circulation capable of pro- 
ducing dropsy ? The only case in which such a cause could 
possibly operate, would be when the thoracic duct was ob- 
structed ; for, as to the lymphatic vessels, they anastomose so 
freely, that the obliteration of a few of them could never ob- 
struct the circulation. But, in the few cases of obliteration of 



LESIONS OP SECRETION. 



247 



the thoracic duct which have as yet been observed, dropsy has 
not been found an invariable attendant ; and in those cases 
where it did exist, there were likewise found other morbid al- 
terations capable of producing it. Besides, in all the cases of 
this description which I have myself had an opportunity of ex- 
amining, the passage of the lymph through the thoracic duct 
was never completely interrupted ; it was carried on by the 
aid of collateral vessels largely dilated, which were detached 
from the duct below the point where the obstruction existed, 
and again opened into it above that point. Thus, then, we 
have as yet no positive proof that an obstacle to the circulation 
of lymph is capable of producing dropsy ; neither can the 
agency of this cause be supported by theory, since the func- 
tions of the lymphatic system, as well as the origin of the fluid 
which it contains, are far from being well known. 

Hitherto we have seen dropsy produced under the influence 
of appreciable causes, residing either in the solids, or in the 
fluids. But there are also some cases of dropsy, in which 
there is no evidence whatever of the agency of any of these 
causes : in which the effusion cannot be traced to any irrita- 
tion, present or antecedent, to the suppression of any secre- 
tion, to an alteration of the blood, or to any mechanical obsta- 
cle to the venous or lymphatic circulation. The individuals 
who present these dropsies which occur without any apprecia- 
ble cause, may be divided into two classes : in the first, they 
constitute the primary disease ; in the second, they are conse- 
cutive, and occur as a complication in the last stages of vari- 
ous chronic disorders. In both these cases, the dropsy might 
reasonably be supposed to depend on a morbid condition of 
the blood, but of this there is no positive proof. It is true, that 
in those individuals who become dropsical during the course 
of chronic diseases, the condition of the blood bears a strong 
analogy to that which produces dropsy in persons that have 
been too largely bled ; that is to say, its quantity diminishes, 
and its proportion of fibrine constantly decreases. But, if such 
be the real and only cause of those dropsies which make their 
appearance towards the close of various chronic diseases, how 
comes it, that this affection is so rare in cases of tubercles in 



248 LESIONS OF SECRETION. 

the lungs, in which the hasmatosis is so materially altered, and 
is, on the contrary, so constant an attendant on cancerous af- 
fections of the uterus ? The conclusion at which we must 
arrive is, that there are some dropsies, with the causes of which 
we are at present perfectly unacquainted. As to saying that 
they depend on an irritation of secretion, it is a mere petitio 
principii; as well might we attribute dropsy, with the older 
nosologists, to an alteration in the organic sensibility of the ab- 
sorbent vessels, or to a defect of proportion between the 
absorbants and exhalants. Before, however, we venture to 
pronounce positively that a dropsy does not depend on any of 
the causes above enumerated, we should ascertain, by actual 
dissection, the state of the parts ; for there are several of these 
causes which must escape detection during life. For example, 
how are we to ascertain, before death, the existence of coag- 
ula in the veins, or of certain morbid states of the liver, in 
which, without the slightest pain, or appearance of jaundice, 
that viscus diminishes in size, and its capillary system is re- 
duced to such a state of atrophy, as with difficulty to allow a 
passage to the blood which arrives by the vena porta? ? and 
yet this state of the liver, so difficult, not to say impossible, to 
be detected during life, is one of the most frequent causes of 
ascites. 

The exhalation of fat may, like that of serum, increase, un- 
der certain circumstances, to such a degree as to constitute a 
disease. This excessive secretion of fat may be either general 
or local ; in the latter case it forms tumours of various sizes 
constituting that affection generally known by the name of li- 
poma. The texture of these tumours is composed of fat of 
greater or less density ; in their interior are found numerous 
septa on which blood-vessels ramify, and which are only the 
parietes of the adipose cells increased in size and thickness. 

Fatty tumours are most commonly formed in the subcuta- 
neous and intermuscular cellular tissue ; they are sometimes 
found in considerable numbers under the skin. I had once an 
opportunity, (the only one, I believe, on record,) of observing 
a fatty tumour in the submucous cellular tissue of the small in- 
testine, near the duodenum : it raised the mucous membrane 



LESIONS OF SECRETION. 249 

on its surface, and, both in its form and structure, was perfectly 
similar to those which are found under the skin. 

We are altogether ignorant of the cause which thus pro- 
duces, in a determinate point of the body, an excessive exhala- 
tion of adipose matter ; the only phenomenon which we can 
appreciate is an extraordinary increase of secretion, unaccom- 
panied by any other morbid process. In some cases, however, 
the formation of these tumours has been known to follow local 
irritation. For instance, in the Memoires de Chirurgie de 
Geneve, there is a remarkable case recorded of an individual 
in whom a blow received on the upper and inner part of the 
thigh was followed by the developement of a tumour in the 
same spot, which, on examination, was found to consist of adi- 
pose matter, and was in every respect a common lipoma. Here 
again, we have an illustration of the principle which I have so 
long, and so often, insisted on ; namely, that irritation may be 
the exciting cause of every species of alteration both of nutri- 
tion and secretion ; but that, of itself, it is incapable of pro- 
ducing any one of them.* 



* Nothing is more common than to observe in the animal oeconomy dissimilar 
effects produced by one and the same cause. For instance, how endless is the 
variety of symptoms presented by individuals who have received syphilitic infec- 
tion from the same source. Again, how different are the general symptoms in 
persons who have contracted measles or small-pox from the same contagion. 
The following fact, related by Johnson (Influence of Tropical Climates on Eu- 
ropean Constitutions), is particularly interesting. 28 soldiers were employed at 
work in the neighbourhood of an extensive marsh in America ; every one of the 
party fell sick, but not all of the same complaint. 3 died of cholera, 5 of dysen- 
tery, 4 of adynamic fever accompaneid with yellow colour of the skin, and all the 
others were seized with intermittent fevers of a maligaant character. Here then 
is a remarkable instance of different forms of disease resulting from the applica- 
tion of the same miasmata. 



Vol. I. 33 



250 LESIONS OP SECRETION. 

ARTICLE II. 

Hypercrinia, with Discharge of tlie Fluid. 

Many diseases were classed by the nosologists of the last 
century under the generic appellation of fluxes, which were 
chiefly characterized by an external discharge of fluid. If, 
however, we suppose that every modification of secretion is 
necessarily connected with some alteration of the solid which 
secretes it, it follows, that the modification of secretion is only 
a symptom, and that the disease should be named, not after it, 
but after the lesion of the solid which causes it. Accordingly, 
such has been the system adopted in the greater number of 
cases. We now no longer maintain the old doctrine, that in 
all cases of increased discharge from the mucous membranes, 
these membranes only serve as a sort of filter, through which 
certain deleterious humours are separated from the blood ; 
neither do we believe that those diarrhoeas which terminate 
certain chronic diseases, depend on a species of liquefaction of 
the nutritive substance, the constant expulsion of "which pro- 
duces marasmus. These doctrines are no longer received, be- 
cause the existence of such a liquefaction is proved by no fact 
whatever, and because we have learned from morbid anatomy, 
that the fluxes of mucous membrane are in general merely the 
effect of some local morbid action, to which these membranes 
are so particularly liable. It may, however, be fairly question- 
ed, whether the adoption of these views resolves all difficul- 
ties, and whether by the total rejection of the class of fluxes, 
we have not neglected and overlooked several facts of impor- 
tance. May not the flux constitute, in some cases, so predom- 
inant a symptom, that, of itself, and independently of the cause 
from which it proceeds, it is capable of producing the most 
serious consequences ? And, what is still more important to 
determine, is it not against this symptom that our treatment 
should principally be directed 1 Does it not often happen, that 
the part from which the discharge proceeds, on dissection, ex- 



LESIONS OF SECRETION. 251 

hibits no morbid alteration, or at least so slight a deviation 
from its healthy appearance, as by no means to correspond 
with the severity of the symptoms ? And, lastly, are there not 
several diseases in which the cause of the flux must be sought, 
not in the texture of the solid from which the discharge pro- 
ceeds, but in some of the other solids ? Let us take the skin, 
for example, and in what other class than that of fluxes, shall 
we place those profuse sweats which exist during the course 
of various acute and chronic diseases, and sometimes consti- 
tute so predominant a part of the affection, that an epidemic 
disease has thence received its name (la suette, morbus sudato- 
rius). I readily admit, that in this case there exists at the same 
time some lesion of one or more of the internal organs ; but 
it is also indisputable, that the profuse cutaneous exhalation 
does not depend exclusively on these organic lesions, and that 
the only appreciable morbid phenomenon which the skin itself 
presents, is an increased activity in its natural function of per- 
spiration. By what other name than that of flux, can we des- 
ignate those local perspirations which are so abundant in the 
axillae, or at the soles of the feet, of some individuals ; or those 
profuse general sweats, which fatigue and exhaust certain per- 
sons whose health is in other respects not affected ? We fre- 
quently observe such perspirations in convalescents ; they dis- 
appear as the strength is re-established, and are often success- 
fully treated by tonics and astringents, applied directly to the 
cutaneous surface, or administered internally. How else, than 
as a species of flux, are we to consider those cold sweats 
which sometimes cover the bodies of the dying ? a phenome- 
non which, notwithstanding the frequency of its occurrence, 
has never yet been satisfactorily accounted for. Neither can 
we better explain why acute rheumatism of the joints is of all 
inflammatory affections that in which perspirations are the most 
frequent and the most copious ; or why, in persons with pulmo- 
nary tubercles in a state of suppuration, profuse sweats are 
such a constant symptom, whilst, in those labouring under 
chronic gastritis, there is in general such a remarkable aridity 
of the skin. May we suppose, that, in the phthisical patients, 
the cutaneous transpiration serves as a substitute for the pul- 



252 



LESIONS OF SECRETION. 



monary transpiration which is suspended ? The cause of these 
differences is of little importance for our subject ; the fact of 
their existence is sufficient to show that, in a nosological ar- 
rangement, many cases of perspiration deserve to be classed 
and described by themselves, and that the only class they can 
with propriety be arranged under is that of fluxes. 

Several diseases of mucous membranes in like manner pre- 
sent as their principal, or even as their only symptom, an 
abundant discharge of fluid, which may be either blood, serum, 
or mucus. 

The bloody fluxes of the mucous membranes must not be 
confounded with the inflammatory affections of these mem- 
branes : an epistaxis is not a coryza. It is true, that in both 
cases there almost always exists in common the phenomenon 
of sanguineous congestion, but then there are other circum- 
stances to be taken into account. 1. In the haemorrhage, the 
conditions of the hyperaemia are such, that the blood, instead 
of accumulating in the vessels of the mucous tissue, eseapes 
from them as fast as it arrives ; but how the vessels are in 
such cases modified, in order to allow the escape of the blood 
which traverses them, is a mystery which we are totally 
unable to divine. 2. The hyperaemia is not in this, as in in- 
flammatory affections, necessarily of a sthenic or active char- 
acter ; it may also be either passive, or produced by a mechan- 
ical obstacle to the venous circulation ; as I have already ex- 
emplified when treating of the different species of hyperaemia. 
3. The existence of vascular congestion is not essential to the 
production of every species of haemorrhage ; it is sufficient 
that the qualities of the blood should be so modified, that its 
molecules lose their natural form of cohesion ; in which case 
the blood escapes from its vessels with the greatest facility, 
and haemorrhages occur simultaneously in different parts of 
the body, totally unconnected with the presence of any irri- 
tative or inflammatory action. We have examples of such 
haemorrhages in scurvy, in typhoid diseases, and in all those 
diseases where, from our knowledge of the exciting causes, or 
the inspection of the blood, we have sufficient evidence of the 
quality and properties of that fluid having been altered. 



LESIONS OF SECRETION. 253 

To this species of haemorrhage should, I conceive, be re- 
ferred a case of haematuria, which I had an opportunity of ob- 
serving in an old woman labouring under a cancerous affec- 
tion of the stomach. About a fortnight before her death, nu- 
merous purplish spots appeared on the skin, and during the 
same time a quantity of blood was passed each day with the 
urine. Red spots likewise appeared on the conjunctiva of 
both eyes, one of which presented exactly the appearance of 
chemosis. On examining the body, a number of ecchymosed 
spots, similar to those on the skin, were found in the cellular 
tissue subjacent to the pleura and peritoneum ; on the internal 
surface of the cavities of the heart ; and in different portions 
of the alimentary canal. The urinary passages contained a 
bloody fluid, and, on pressure, a similar fluid was made to 
exude from the mamillae of the tubular substance of the kid- 
neys. Neither in the heart, nor in any of the large vessels, 
could we discover any thing except a violet coloured fluid, 
without the slightest appearance of coagulation. A case pre- 
cisely similar has been lately reported by M. Stoltz, in the 
Archives de Medicine, vol. xv. In this case also, there was an 
appearance of chemosis produced by the same cause. The 
individual was a woman, who at the time was pregnant ; and 
what renders the circumstance peculiarly interesting is, that 
ecchymoses similar to those in the mother were likewise found 
in the lungs, pericardium, heart, and vessels of the fetus. 

The following fact has been related by Doctor Schreyer 
{Bulletin des Sciences Medicales, April 1828). Of a family 
consisting of five children, the eldest died of haemorrhage from 
having accidentally bitten his tongue ; the second and fourth 
are robust healthy children ; but the third and fifth have a re- 
markable disposition to haemorrhage : they are all five of the 
male sex. 

The third, whose age is five years, and the fifth, fifteen 
months, both present, at variable intervals, on their legs and 
thighs, a number of blue spots which swell to the size of a 
pigeon's egg, and then assume a yellowish green shade : they 
do not bleed, unless when opened artificially, but then the 
haemorrhage continues until the patient falls into a swoon, and 



254 LESIONS OP SECRETION. 

his body becomes pale as death. The blood which flows is at 
first red, but subsequently resembles water in which raw meat 
had been steeped, and at this period of the haemorrhage the 
blue colour of the spot disappears. The further progress of 
the bleeding is arrested by the pressure of the fingers on the 
orifice, which the parents state it is generally necessary to con- 
tinue for the space of twenty-four hours. The orifice is never 
closed by a well formed coagulum. The children recover 
slowly, but then continue to all appearance healthy, until the 
next renewal of the haemorrhage. The eldest once had an at- 
tack of haemorrhage from a carious tooth, by which he was 
excessively reduced : the youngest has not this disposition to 
so great a degree as his brother. Neither the father nor 
mother, nor their parents, have ever had any similar attack. 

The perspiratory fluid which is constantly exhaled in the 
form of vapour, on the surface of mucous membranes, as it is 
on every other surface, whether serous, cellular, vascular, or 
cutaneous, is sometimes exhaled in much larger quantities than 
usual; instead of vapour, it then assumes the fluid form, and 
in this way the mucous membrane sweats precisely like the 
skin. This exhalation or flux may be very considerable with- 
out being accompanied by any remarkable organic disease of 
the membrane. The enormous quantity of fluid which in this 
way escapes in a very short time from the system, may pro- 
duce a series of morbid phenomena, analogous to those pro- 
duced by other great evacuations ; of which the following are 
the principal. 1. The blood becomes remarkable for its deep 
black colour, and for the predominance of its fibrinous part ; 
both of which alterations result from the fact of the serous ex- 
halation having deprived the blood of its albuminous portion. 
2. The activity of the other secretions is diminished, or alto- 
gether suspended. 3. The cutaneous surface becomes sud- 
denly cold, and its usual perspiration ceases. 4. The strength 
sinks rapidly. 5. Various functional derangements of the 
nervous system occur, similar to those which so frequently 
succeed to great losses of blood, and which should not, in all 
cases, be regarded as proceeding from a real exaltation of the 
forces of that system. 



LESIONS OF SECRETION. 255 

The production of this serous flux does not appear to be 
connected with any determinate degree of irritation ; in fact, 
the slightest irritation is just as effectual in producing it, as the 
most intense. It is sometimes established after the sudden 
suppression of a profuse sweat ; the impression of cold and 
moisture on the skin of individuals who had been previously 
exposed to a high temperature, is likewise not unfrequently 
followed by a copious serous flux from the intestines. Another 
case in which this flux sometimes occurs, is when a dropsy 
suddenly disappears, and a fluid similar in appearance to the 
dropsical effusion flows from the surface of some mucous mem- 
brane. In this way I have seen the sudden absorption of a 
hydrothorax followed by an abundant serous discharge from 
the mucous membrane of the air passages ; and an ascites re- 
placed by an intestinal flux, which seemed to consist of a pro- 
digious quantity of watery fluid. In these different cases, I 
see no reason why we may not suppose that it is the same fluid 
which being absorbed from one of the serous cavities, and car- 
ried into the torrent of the circulation, is subsequently sepa- 
rated from the mass of the blood on one of the great elimi- 
nating surfaces : it is thus that water, injected into the veins 
of a living animal, escapes by the mucous membrane of the 
bronchia : and thus also, we constantly observe various fluids 
taken up by absorption into the mass of the blood, and separa- 
ted from it with the urine. 

There is a very extensive class of diseases, which the older 
nosologists designated by the term catarrhal affections, and 
which they carefully distinguished from inflammatory diseases. 
These affections generally occur in individuals of a soft lym- 
phatic temperament, are most frequent in cold and wet coun- 
tries, and are especially characterized by an excessive secre- 
tion from the different mucous membranes, with or without 
some febrile excitement attending. Their treatments used to 
consist in modifying the mucous secretion by the use of aro- 
matics, bitters, purgatives, or cutanous revulsives ; bleeding 
was seldom had recourse to, and emollient drinks were alto- 
gether proscribed. As it is the fashion of the present day to 
regard all mucous fluxes as simply the results of inflammatory 



258 LESIONS OP SECRETION. 

action, they have consequently ceased to be classed and de- 
scribed as distinct from inflammations of the mucous mem- 
branes : in this instance again, I cannot help thinking that we 
have refined too much, and pushed our theories too far. We 
may surely suppose an accidental increase in the secretion of 
the mucous follicles, independently of any inflammatory action ; 
just as we constantly see the secretion of urine increased by 
the agency of different causes, without the existence of nephri- 
tis. Is there always stomatitis in those cases in which, under 
the influence of a moral emotion, the mouth becomes parched, 
or the tongue suddenly loaded with an unusual quantity of mu- 
cus ? But even supposing that every mucous flux must neces- 
sarily be preceded by irritation, (which yet in many cases is 
supposed rather than proved,) it will be always necessary to 
admit some peculiarity in the mode of irritation ; for, after 
death its existence is not manifested by any appreciable lesion. 
For example, I have frequently found on dissection, especially 
in infants, the mucous membrane of the intestines perfectly 
white, and presenting its natural thickness and consistence, in 
cases both of acute and chronic mucous diarrhoea: neither 
have I found any more appreciable lesions in the bronchial 
mucous membranes of individuals affected with chronic pulmo- 
nary catarrh. Moreover, it cannot be denied that several of 
these mucous fluxes are most successfully treated by different 
substances all more or less stimulant. How many of the in- 
testinal mucous fluxes, for instance, yield to the employment 
of astringents, or bitter purgatives ; in a word, to substances 
which appear to act by substituting a new modification of the 
mucous follicles in the place of the former ? I am acquainted 
with the case of a female, who was teazed with difficult di- 
gestion accompanied with constant copious vomiting of a glairy 
mucous fluid, and who was cured by the use of rhubarb and 
chalybeate waters. I may remark, by the way, that it would 
be a great error to suppose that the fever which accompanies 
certain acute mucous fluxes, is an infallible proof of their in- 
flammatory nature ; for the simple fact of an organ's being 
deranged in its nutrition, secretion, or innervation, is sufficient 
to generate fever, no matter whether that derangement be 



LESIONS OP SECKETION. 257 

attended with the augmentation, diminution, or perversion of 
the vital powers of the organ : the bare circumstance of a part 
of the living body being in a state of suffering, whatever the 
nature of that suffering be, is sufficient to light up the various 
sympathies which constitute fever. The existence of fever 
does not, therefore, necessarily imply the idea of stimulus or 
of excessive action ; and consequently the object of the prac- 
titioner should not, in every case of fever, be to combat this 
stimulus, but in some cases it should be to relieve a derange- 
ment, either circumscribed and purely local, or affecting gen- 
erally the blood itself, or the centres of the nervous system. 
In many instances, the true indication of treatment consists 
neither in debilitating nor stimulating, in drawing blood nor 
administering tonics ; as is exemplified in certain fevers which 
resist alike the use of the lancet, and the administration of cin- 
chona, but yield to the employment of purgatives. 

The secretion of the different glandular organs may, like 
that of the tegumentary membranes, increase considerably in 
quantity, without the secreting organ appearing in any degree 
altered in its texture. Thus, for instance, I have frequently 
found the liver and its appendages free from any appreciable 
lesion, in individuals whose alimentary canal, in some cases 
sound, in others diseased, contained an unusual quantity of 
bile ; or who during life had passed an enormous quantity of 
that fluid by stool or by vomiting. I have had an opportunity 
of examining the bodies of four persons who died of diabetes : 
in one only, the kidneys were remarkable for their size, and 
the congested state of their blood-vessels ; in the other three, 
the kidneys presented no remarkable appearance whatever. 
In the case of a man too who for a length of time previous to 
his death had an incessant ptyalism, for which he could assign 
no satisfactory cause, the salivary glands presented, on dis- 
section, not the slightest vestige of any morbid appearance ; 
and on the other hand, we do not observe that inflammation 
of the parotid glands is accompanied by any remarkable in- 
crease of the salivary discharge. Is not the flow of tears pro- 
duced by a moral impression, another example of an action 
sui generis, and independent of any inflammatory action? 

Vol. I. 34 



258 LESIONS OF SECRETION. 

From these facts, we are, I conceive, warranted in concluding, 
in the imperfect state of our knowledge respecting what passes 
in the interior of a gland when its secretion is augmented, that 
the cause of that augmentation, whatever it be, is at least in- 
dependent of any other morbid action ; and in appropriating 
the term Jlux to designate such an augmentation. 

The- facts I have now stated, and the considerations which 
they have suggested, induce me to admit, under the title fluxes, 
a certain class of diseases, in which the external discharge of 
a fluid constitutes the principal phenomenon, that to which all 
the other symptoms are subservient, and against which the 
application of remedies should be especially directed. These 
characters are all applicable to the disease known by the name 
of cholera morbus. The principal feature which characterizes 
its existence, is an excessive evacuation of bile, mucus, or 
serum ; all the other symptoms depend principally on the ex- 
treme abundance of these evacuations, and their suppression 
is the main object indicated. Hence, opium has been found 
so successful in the treatment of cholera ; and hence, on the 
contrary, the practice of blood-letting, when trusted to exclu- 
sively, has proved so dangerous, or at least so inefficacious a 
remedy. 

Fluxes may, with respect to their seat, be divided into two 
classes ; those from membranes, and those from the glandular 
tissues. 

With respect to their nature and composition, they may be 
distinguished into three species. 1. Bloody fluxes. 2. Serous 
fluxes. A fluid more or less analagous to the serum of the 
blood forms the principal, if not the only ingredient, in a great 
proportion of the fluxes from the cutaneous and mucous mem- 
branes, and likewise in some of those from parenchymatous 
organs. For instance, in diabetes insipidus, the urine is almost 
wholly composed of a serous fluid. 3. Lastly, we must ad- 
mit a third species of flux, produced by an excessive secretion 
of the different fluids furnished by the secretory organs, prop- 
erly so called ; such as mucous, salivary, bilious, and urinary 
fluxes, &c. 



LESIONS OP SECRETION. 259 

Fluxes, wherever they are seated, or of whatever materials 
they are composed, may be either acute or chronic; active or 
passive ; continued or intermittent ; sporadic or epidemic, or 
even endemic. The existence of all these varieties has been 
already sufficiently established by the facts adduced in the 
preceding part of this article. 

The organ from whence the flux proceeds, may present any 
of the following appearances. 1. The same condition and ap- 
pearances which, to the eye of every anatomist, constitute its 
natural state. 2. A remarkable colouring of its tissue. 3. A 
sanguineous congestion, either active, passive, or mechanical, 
unaccompanied With any other alteration. 4 Different al- 
terations of texture. In general, however, the apparent slight- 
ness of the morbid alteration of the part, forms a striking con- 
trast with the violence of the symptoms. 

Besides the alterations in the organ from which the flux pro- 
ceeds, we frequently find it resulting from other causes, which 
I shall now enumerate. 1. A state of irritation in the mem- 
branes on which the secreting organ pours its secretion. 2. 
Some modification of the nervous influence : thus, there is not 
a secretion which may not be suddenly increased by a strong 
mental emotion. 3. The sudden or gradual suspension of 
other secretions ; to this source may perhaps be traced one of 
the causes of the endemic cholera morbus of the East Indies. 
4. The absorption of a fluid which had accumulated in the 
areolae of the cellular tissue, or in the serous cavities. 5. The 
elimination from the system, of various foreign substances 
which had been taken up by absorption. 

The influence of a flux on the constitution may be either 
beneficial or injurious. The injurious effects may result either 
from the exhaustion it produces, or the morbid sympathies it 
excites. It may prove beneficial, by carrying off deleterious 
substances which had been introduced into the blood, or by 
consisting itself of a deleterious matter, or by causing a deter- 
mination towards the organ from which it proceeds, attended 
with the cessation of a morbid action which had been going 
forward in some other part. 



260 LESIONS OF SECRETION. 



CHAPTER II. 



Modifications in the Situation of the Secretions. 

This class of the modifications of secretion, which may be 
designated by the term Heterocrinia, has hitherto received but 
little attention from pathologists. The doctrines most gen- 
erally received in the modern schools naturally prevented 
their obtaining that share of attention which their importance 
merited*, and the facts by which their existence was establish- 
ed, were either rejected in toto as irreconcilable with some 
favourite theory, or else admitted under the condition of being 
interpreted in its favour, and made to conform with the par- 
ticular views of the theorist. A more accurate, and what is of 
still greater importance, a more disinterested observation, will, 
no doubt, add considerably to the number of those facts which 
we at present possess ; and those well acquainted with med- 
ical literature might find additional information in the writings 
of our predecessors, many of whose theories were formed in 
consequence of their having observed several facts of this 
description ; and perhaps in some cases, the cause of the facts 
being observed might be traced to their conformity with some 
favourite theory or preconceived idea of the observer. I do 
not mean to insinuate that our predecessors were deficient in 
the art of observing ; but, being less precise in their manner 
of describing facts, and deducing their conclusions, they had 
fewer chances of discovering the truth ; and, when they had 
found it, but too frequently perverted its import by their 
vicious methods of observing and reasoning. For this reason 
it was, that the humoral metastasis, which they admitted, came 
afterwards to be regarded as a mere chimera, although mod- 
ern observations have since clearly proved that the doctrine of 
metastasis is by no means destitute of foundation. Let us 
then endeavour to ascertain how much of this doctrine is sup- 



LESIONS OF SECRETION. 261 

ported by facts, and, as indifferent to the theories of the past, 
as to those of the present day, let us not shrink from the con- 
clusions to which these facts seem legitimately to lead. 

Several of the products of secretion have been found at a 
distance from the place in which they are naturally separated 
from the blood. Sometimes they are found containing all 
their usual ingredients ; in other instances they contain only a 
certain number of those ingredients. 

A fatty substance has sometimes been observed in the 
blood, presenting the appearance of small oily drops, sus- 
pended in the general mass" of fluid contained in the blood 
vessels. A case of this description has been related in the 
15th volume of the Archives Generates cle Medicine. 

I do not rank in the list of heterocrinias, either accumula- 
tions, or discharges of serous fluid ; because, wherever they 
occur, the serum is in fact only increased in quantity ; instead 
of existing in the form of vapour, it assumes, in consequence 
of its increased quantity, the fluid form ; but this alteration is 
widely different from the definition we have given of hetero- 
crinia. 

Certain secretions of fat may, however, be considered as 
belonging to the class of heterocrinias. I have, for instance, 
on two occasions found in the submucous cellular tissue of the 
intestines, small fatty tumours perfectly analogous in their 
form, external appearance, and composition, as well as in the 
cellular envelope by which they were surrounded, to the fatty 
tumours which are often formed under the skin. I need 
scarcely remark, that, in the natural state, fat is never found 
in the dense compact cellular tissue which lines the mucous 
membranes. 

I am not aware of any instance of mucus being found any 
where, except on the free surface of the mucous membranes. 

Some cases have been recorded, in which one of the con- 
stituents of milk, caseum, was discovered in parts where it is 
not usually contained. M. Cabal ascertained the existence of 
a substance possessing all the properties of caseum in the 
urine of a widow who had never had children. It is also 
stated in the Bulletin des Sciences Medicates for the year 1826, 



262 LESIONS OF SECRETION. 

that a substance perfectly analogous to caseum was found in 
the peritoneum of a woman who died of inflammation of that 
membrane. 

M. Hervez de Chegoin has lately communicated to the 
Academy of Medicine a case in which caseum is likewise 
stated to have been detected in the urine. A woman, on the 
fourth day after her delivery of a dead child, was seized with a 
miliary eruption ; the breasts were not at all swollen, and pre- 
sented no symptom of any secretion of milk : she died on the 
tenth day. The urine was analyzed by M. Petroz, principal 
chemist and apothecary to the hospital of La Charite, and by 
him was pronounced to contain caseum. 

It appears that, in these cases, there was no milk secreted 
in the breasts ; and consequently we cannot suppose that the 
caseum was formed in the mammary glands, and thence re- 
moved by absorption to other parts of the system. A more 
important point, however, to determine, is whether the caseum 
of the milk is perfectly identical with the morbid matter found 
in the urine and elsewhere, to which the same name has been 
applied. This identity is extremely difficult to establish, inasmuch 
as, according to Orfila, in the present state of the science, we 
possess no means of distinguishing caseum from several other 
organic principles. T must not omit to mention, that, in a 
course of lectures delivered this year (1828) at the College de 
France, by a highly talented and experienced chemist, M. Du- 
mas, it was announced, that a substance in every respect simi- 
lar to caseum formed one of the ingredients in the composi- 
tion of pus ; so that this principle can no longer be considered 
as exclusively the product of the mammary secretion. 

It is exceedingly common to find a yellow colouring matter 
exactly similar to that of bile, mixed with the fluids, or com- 
bined with the different solids. It is this that characterizes 
jaundice. This peculiar colour generally co-exists with some 
disease of the liver or its appendages ; in some cases, however, 
neither the symptoms which occur during life, nor the appear- 
ances found on dissection, afford any proof of such disease 
having existed. 



LESIONS OF SECRETION. 263 

Another principle, named cholesterine, which is generally 
considered as belonging more especially to the bile, has been 
found in various parts both of the solids and fluids. Not only 
does it enter into the composition of certain biliary calculi, but 
it has likewise been detected in the brain of man and several 
animals ; in a diseased lung — Gmelin ; in a liver which con- 
tained an abscess — idem; in a human tongue injected and pre- 
served — Woehler ; in the fluid of a hydrocele ; and in some of 
those tumours which are called scirrhous. (It has likewise 
been discovered in musk, and in certain species of mush- 
rooms). Hence it would appear, that cholesterine is one of 
the most generally diffused principles in the human ceconomy, 
and that almost every tissue is capable of forming it, or of sep- 
arating it from the blood. 

The ancients made frequent allusions to the possibility of 
urine being secreted in other ways than by the kidneys ; in- 
deed there is scarcely a part of the body in which they do not 
state their having found collections of that fluid. The obser- 
vations they have transmitted to us on this subject, do not, 
however, possess that character of precision, which would 
guarantee their accuracy, or render them available to the in- 
terests of science. In the present state of our knowledge, 
the following propositions embrace all that we can affirm on 
the subject. 

1. Several of the immediate principles of the urine, gene- 
rally considered as belonging to it exclusively, may be found 
in other parts of the body besides the urinary apparatus. 

2. These principles have been found out of the urinary pas- 
sages, both in cases where the renal secretion had been for 
a longer or shorter period suspended, and where the secretion 
of urine went on as usual. 

3. Uric acid has been detected by M. Vauquelin in the 
sweat of individuals whose kidneys were diseased.* Several 
chemists have likewise discovered this acid in the tophaceous 



* Clinique Chirurgicale de M. Pelletan, torn. ii. p. 369. 



264 



LESIONS OF SECRETION. 



concretions which are found situated in and about the joints 
of gouty persons. 

4. Urea also has been detected out of the urine. 

5. A fluid has been seen passing off by different outlets, 
which in its physical properties, bore an exact resemblance to 
urine, and which on being analyzed, was found to contain one 
or more of the immediate principles of that fluid. The follow- 
ing fact, related by Dr. Arnold,t appears to me particularly 
interesting, and, in the present state of the science, highly im- 
portant. 

Maria Burton, aged twenty-seven, of a strong constitution, 
enjoyed uniform good health until the month of June, 1820, at 
which period she was seized with haemoptysis, and suppres- 
sion of the catamenia. Under the use of copious venesec- 
tions and emetics, she was relieved from the haemoptysis, but 
had no return of the menstrual discharge. For two years 
after this period it was necessary to introduce the catheter 
once every twenty-four hours, in order to draw off the small 
quantity of urine which was secreted into the bladder. When- 
ever the introduction of the instrument was neglected, a fluid 
apparently urinous was seen to exude in considerable quanti- 
ties through the integuments of the lumbar region. 

In September 1822, the introduction of the catheter was 
omitted for seventy-two hours, during which period a new 
phenomenon was presented. A fluid in every respect resem- 
bling urine issued from the right ear, at first in single drops, 
and afterwards in larger quantities. This discharge continued 
in variable quantities, and at irregular intervals, every day for 
a considerable length of time : the average quantity discharged 
during the twenty-four hours might be estimated at about 
eight ounces. The discharge was always preceded by a very 
distressing sensation in the eye and ear of that side, which 
generally continued until the discharge was fully established ; 
and if at any time the evacuation from the ear was less abund- 
ant than ordinary, or did not recur at the usual period, the 



t The New-England Journal of Medicine and Surgery. Boston, 1825. 



LESIONS OF SECRETION. 265 

patient was seized with general anxiety, excruciating headach, 
and delirium. Sometimes the delirium was not preceded by 
headach ; and on other occasions the suppression of the dis- 
charge was succeeded by violent tetanic spasms, after which 
she gradually swooned away and fell into a state of perfect 
insensibility, which was occasionally interrupted by starts, 
deep drawn sighs, convulsive laughter, and tetanic immobility 
of the lower jaw. This state of insensibility, accompanied 
with an almost perfect cessation of arterial pulsation, and ex- 
treme lentor of the respiratory movements, continued on one 
occasion for twenty-four hours. The right ear gradually be- 
came insensible to the impression of sounds, and the sight of 
the right eye was likewise lost. These different symptoms 
continued during the latter part of the year 1822, and for the 
two succeeding years, 23 and 24 ; during which time the dis- 
charge took place successively from the right ear, then from 
the left, and afterwards from the left eye, in which it produced 
a violent inflammation. On the 10th of March 1823, the pa- 
tient began to vomit a fluid perfectly similar to urine. On 
the 21st of April, the right breast became swollen, hard, and 
painful ; shortly after which, a few drops of fluid were ob- 
served to issue from the nipples. At the end of twenty -four 
hours these phenomena disappeared, and, in a week after, 
they returned : on their second appearance, the fluid which 
issued from the nipple presented the same colour as urine, and 
on analysis was found to contain urea. This discharge con- 
tinued until the ensuing autumn ; occasionally, however, it 
changed to the left breast. On the 20th of November, the 
fluid assumed a whitish colour, and presented the same ap- 
pearance as milk largely diluted with water. This new secre- 
tion continued until the 12th of December, on which day the 
fluid reassumed its former colour. 

On the 10th of May, the umbilical and hypogastric regions 
became tense and painful ; and soon after, a fluid similar to 
that which had previously made its escape by so many differ- 
ent outlets, was observed trickling down from the umbilicus. 
This discharge continued for some time, and increased grad- 
ually in quantity. Lastly, on the 30th of July 1823, another 
Vol. I. 35 



266 LESIONS OF SECRETION. 

discharge of the same nature as the preceding was established 
from the nose, and continued for several months, flowing oc- 
casionally in such considerable quantities as to constitute a 
copious flux. 

All the fluids which issued from the several outlets just enu- 
merated were analyzed and found to contain urea ; in addition 
to which they also contained the following substances. 1. 
Some alkaline sulphates ; as was ascertained by testing with 
muriate of barytes and ascetic acid. 2. Some muriates ; 
which were detected by the nitrates of silver and of mercury. 
3. Some phosphates ; which were recognized by employing 
potash, ammonia, and lime. The urea was procured by evap- 
orating the fluid, dissolving the residuum in alcohol, and again 
evaporating the solution. 

During the whole of this period, a small quantity of urine 
was constantly discharged by the bladder ; and at different 
times the urinous fluid which issued from the other outlets was 
replaced by pure blood. The quantity of the irregular dis- 
charges was uniformly diminished by frequently introducing 
the catheter, and drawing off" the urine as fast as it accumula- 
ted ; but the discharges never ceased altogether. The quan- 
tity of urine furnished by these supplementary secretions was 
sometimes so considerable, that some imposition might have 
been suspected, if the precaution of standing constantly by the 
patient's bedside had not been taken. 

All the violent nervous symptoms above described con- 
tinued to increase in violence for six months, and then began 
to abate. At present (Autumn 1824) when the urinous fluids 
flow copiously, the patient finds herself in a very tolerable state 
of health, and is able to get up and walk about. The dis- 
charges still continue from the right ear, the right breast, and 
from the umbilicus ; but are neither so frequent nor so abun- 
dant as formerly. A considerable quantity of urine is every 
day voided by the bladder. It is now several months since 
any discharges have taken place by the stomach, nose, or eyes. 
The patient who forms the subject of this extraordinary case, 
was attended by Drs. Arnold, Fisher, Mitchell, and Hosack, 
of New- York. 



LESIONS OF SECRETION. 267 

The general conclusions which the facts just recorded 
naturally suggest, are, that the blood contains, in variable pro- 
portions, the elements of all the secretions ; that, in general, 
these elements are separated from the blood only in certain 
organs, the peculiar structure of which favours that separation ; 
and that after their separation they are so united and com- 
bined in their respective organs as to form the different secre- 
tions ; thus, bile is formed in the liver, urine in the kidneys, &c. 
But, under certain circumstances, those elements which are 
contained in the blood may be separated from it by other 
outlets than those through which they naturally pass ; in such 
cases, however, they pass off from the blood single and un- 
combined, so that it is not the secretions as they exist in the 
natural state which are found in other parts than in their re- 
spective secreting apparatus, but merely some of the elements 
of these secretions. Thus, for example, it is not the bile in its 
natural condition, which, in cases of jaundice, imparts the pe- 
culiar colour to the different solids, or enters into combination 
with the various fluids ; but chiefly one of its elements, namely, 
the colouring matter: neither is it milk in its natural state, but 
simply caseum, which has been found elsewhere than in the 
mammary gland or its ducts, and which M. Dumas affirms he 
has constantly observed in pus. Thus, in like manner, it is 
ui'ic acid, not urine, which is found in the articulations of per- 
sons affected with gout ; and, in the case recorded by Doctor 
Arnold, urea, without uric acid, formed the basis of the fluid 
resembling urine which passed off by the ears and other ex- 
traordinary outlets. 

Three hypotheses may be admitted in explanation of these 
unusual secretions. 1. We may suppose that there exists in 
the blood an exuberant formation of some of the ordinary ele- 
ments of the secretions, and that, in order to relieve the blood 
from their presence, it is necessary that some supplementary 
outlets should be established. 2. We may suppose that these 
elements are combined in the organ destined by nature to 
separate them from the blood, and are subsequently absorbed 
and taken into the circulating fluid, from which they are after- 
wards eliminated in some way or other, just like a foreign sub- 



268 LESIONS OF SECRETION. 

stance injected into a vein, or like pus absorbed from a puru- 
lent collection. 3. Lastly, we may suppose, that the natural 
secreting organ is in such a state, that its functions can no 
longer be performed ; in consequence of which, the materials 
which it should separate from the blood being deprived of 
their natural outlet, have a tendency to pass off by other ways, 
but not in a state of combination, or at least never so perfectly 
combined as when separated by their natural secreting organ. 
It is likewise by an aberration in the situation of the secre- 
tion, that those singular cases can be explained, in which cysts 
containing hair and teeth have been found in different parts of 
the body. These productions cannot be considered as the 
fragments of a foetus, inasmuch as they have been found in 
men, and in other parts of the body besides the abdomen. 



CHAPTER HI. 

Modifications in the Quality of Secretions. 

We have laid it down at the commencement of this volume 
as an established fact, that, wherever a particle of living mat- 
ter exists, a secretion of some kind is constantly carried on. 
Another fact, equally well established, is, that wherever this 
secretion takes place, it is liable to have its qualities consider- 
ably modified ; so that in place of the fluid which should con- 
stitute its natural product, another substance may be found, 
differing from it in a greater or less degree. This morbid pro- 
duction may occupy the place either of the peculiar fluids 
which are furnished by their respective secreting apparatus, 
or, of the perspiratory fluid which is formed in every part of 
the living body. Thus the bile, mucus, saliva, urine, &c. oc- 
casionally present, in their sensible qualities, numerous and 
important modifications, which are, in some cases, connected 
with certain alterations in the circulation or nutrition of the se- 



LESIONS OP SECRETION. 1269 

creting organ, and in other instances are altogether dependant 
on some modifications of the blood itself, or of the nervous in- 
fluence. I shall not at present enter into the consideration of 
the different alterations of these secretions, because their his- 
tory cannot with propriety be separated from that of the or- 
gans by which they are secreted ; which, according to the 
plan of this work, is reserved for the second volume. For the 
present, therefore, I shall confine my observations to those 
morbid productions which are formed in the place of the per- 
spiratory fluid. I must, however, premise, that it is not always 
easy to determine, whether the morbid production which we 
find in an organ is the result of an alteration of secretion of 
this perspiratory fluid, or of an alteration of the nutrition 
of the part. Indeed, these two species of alteration are fre- 
quently combined ; for instance, in scirrhus of the stom- 
ach, there is an evident thickening of the submucous cellular 
tissue accompanied with hypertrophy of the muscular tunic, 
and at the same time it is evident that a new substance is de- 
posited between the molecules of these tissues, and that this 
substance occupies the place of the natural perspiratory fluid. 
Since the perspiratory fluid exists in every part of the'body, 
so likewise the morbid secretion which usurps its place may 
exist in every part. The same force which every where pro- 
duces a perspiratory fluid analogous to itself, independently of 
any peculiar arrangement of matter, or organization, may like- 
wise produce in every part of the system a morbid matter 
equally analogous to itself: thus it is, that tubercle appears in- 
differently in parts the most distant, and most differently organ- 
ized. This morbid production, which presents such an infinite 
variety of appearances, may be either solid, or fluid, or may 
alternately assume those different forms. When once sepa- 
rated from the blood, it has a constant tendency to increase in 
volume ; which is in some instances effected by the simple de- 
position of new particles, constituting growth by juxtaposi- 
tion, and in others, by a spontaneous internal developement, 
similar to that which in the impregnated germ gradually trans- 
forms a drop of fluid into an animated being ; constituting 
growth by intus-susception. The morbid productions whose 



270 LESIONS OF SECRETION. 

growth is accomplished in this manner, may be considered as 
endowed with a certain plastic force, by virtue of which they 
represent, in the several stages of their formation, the devel- 
opement of the embryo, or of the different beings of the ani- 
mal series, and, like them, constantly continue to rise in the 
scale of life and organization. 

Whether these morbid productions remain stationary, or 
continue to increase either by juxtaposition, or intussuscep- 
tion, they are liable to undergo various alterations in their ap-. 
pearance, texture, and physical properties, the cause of which 
may reside either within themselves, or in the surrounding 
parts. If they do not present any trace of organization, or 
betray any symptom of vitality, it is evident, that the changes 
which they undergo cannot result from any action of their 
own, but must necessarily depend on some modification of 
the living parts in which the morbid production is developed. 
For example, if, after having been soft, this production be- 
comes subsequently hard, the change is accomplished by the 
absorption of some of its constituent parts by the surrounding 
tissues. If, on the contrary, after having been hard, it be- 
comes soft, the change will in general be found to depend on 
the irritation caused by its presence in the living tissues, which 
leads them to secrete a new matter, pus, that constantly tends 
toseparatethe particles of the morbid production, forthe purpose 
of thus accomplishing the law by virtue of which every foreign 
body lodged in any part of the living system should be elimi- 
nated from it. (See, farther on, the article on tubercles). If, 
however, the morbid production presents any traces of organ- 
ization or vitality, the cause of its subsequent alterations must 
be sought for both within itself, and also, as in the preceding 
case, in the tissues by which it is surrounded. Snch a produc- 
tion, like every other being endowed with life, has an indepen- 
dent nutrition and secretion of its own : hence arises two se- 
ries of phenomena ; one of which constitutes its physiological 
state, e. g. the formation of vessels, exhalation of serum, de- 
velopement of different tissues, &c. ; and the other, its patho- 
logical, e. g. various derangements of circulation, nutrition, 



LESIONS OF SECRETION. 271 

and secretion, analogous to those occurring in the different be- 
ing endowed with life. 

The tissues in which these morbid productions are devel- 
oped, present some one of the following conditions. 

1. The natural healthy state. In this case, the tissues may 
either have retained their healthy condition from the com- 
mencement, or, having been engaged to a greater or less ex- 
tent at the period of the first formation of the morbid product, 
may have subsequently returned to their physiological condi- 
tion. But even though the surrounding tissue retains its nat- 
ural structure and healthy state, it may, notwithstanding, suffer 
such a degree of compression from the contained morbid pro- 
duction, as to have its appearance considerably altered, and its 
functions in some degree affected. 

2. A state of active hyperaemia. In this case, more or less 
appearance of vascularity is found in the vicinity of the mor- 
bid production ; and, as these productions, when growing by 
juxta-position, occasionally surround, and, as it were, imprison 
some portions of the tissue in which they are developed, it 
follows that the same appearance of vascularity which is found 
about the entire mass, may likewise be discovered in its interior. 

In cases of this description, the vessels which are seen traver- 
sing the morbid mass have erroneously been supposed to be- 
long to the production itself; whereas they in reality appertain 
to the debris of the tissues which were imprisoned within the 
accidental production : the truth of this assertion may readily 
be ascertained by the dissection, or maceration of the part. 
The hyperaemia may present all those varieties of colour which 
we have already enumerated when treating of that subject : 
for instance, we may observe, in the interior of these pro- 
ducts of morbid secretion, or in their immediate vicinity, 
either a red, grey, or a brown tint, or even a more or less deep 
shade of black : when with this latter colour there likewise 
exists a certain degree of induration, the disease is said to be 
complicated with melanosis. The hyperaemia which attends 
on these productions is not necessarily continued ; it may 
cease at intervals, and return at stated periods. Many of the 
products of morbid secretion betray no symptom of their ex- 



272 LESIONS OP SECRETION. 

istence, unless at those periods when a determination of blood 
is thus produced in their vicinity. The influence of the mor- 
bid growth in producing increased determination of blood, 
may be compared to the irritation caused by a foreign body ; 
and when once the hyperemia is established, it re-acts on the 
cause by which it was produced, and in its turn causes an in- 
creased activity in the process of secretion ; the product of 
which is sometimes analogous to the original morbid produc- 
tion, and in other cases presents quite a different aspect, being, 
for example, either blood or pus. 

3. Some modification of the consistence of the molecules of 
the surrounding tissue. From these alterations of the parts 
adjacent to the morbid production, arise the several degrees of 
induration and softening which we sometimes observe in its 
vicinity. 

4. Some modification of the number of the molecules of the 
surrounding tissue. Hence arises in some cases a considerable 
degree of hypertrophy, and in others, such a remarkable degree 
of atrophy, that the entire substance of the tissue or organ grad- 
ually disappears, as the morbid secretion increases in size. It 
would appear in these cases, that when the force of secretion 
predominates in the cellulo-vascular structure of the organ, 
there is at the same time a diminution of that other force by 
which the particles destined to constitute the proper tissue of 
the organ are separated from the blood. This state of the af- 
fected organ is in some sort analagoUs to what passes in the 
system at large, when the entire body becomes emaciated in 
consequence of the extraordinary activity of the secretions. 
The state of atrophy which thus accompanies the increased ac- 
tivity of a secretion, certainly indicates a modification of the 
organic actions, but we have no proof whatever that it results 
from irritation. 

5. A secretion of pus. This secretion takes place either 
around the whole mass of the accidental production, or be- 
tween its different parts when they are divided by portions of 
the tissue of the organ, which remain imprisoned within it. 
The period of softening of accidental productions appears to 
me nothing more than the result of a secretion of pus, which 



LESIONS or SECRETION. 273 

takes place in the manner I have already attempted to de- 
scribe, either around these productions, or in their interior : in 
the first case, the softening commences at the circumference, 
and passes to the centre ; in the second, it passes from the 
centre to the circumference. The molecules of the morbid 
production are separated, and in a manner diluted by the 
newly secreted pus, by which means they are more easily re- 
moved from the system, like foreign bodies, by outlets accident- 
ally formed for their evacuation. In [the place which had 
been occupied by the morbid secretion, there generally re- 
mains a solution of continuity, a sort of ulcer, which in some 
cases cicatrizes, in others continues for an indefinite period to 
secrete either pus, or else a substance more or less similar to 
that of which the original morbid production was composed. 
Thus we observe in this group of morbid phenomena, as well 
as in the several healthy functions, a series of organic actions, 
constantly succeeding each other in the same determinate 
order, and with the same ultimate object. 

If we endeavour to ascertain the symptoms attendant on the 
developement and progress of these morbid productions, we 
shall find that in some cases they are developed, and continue 
their progress, without giving rise to any symptom either local 
or general, by which their existence could be revealed. In 
other cases, again, although there is no local disturbance in the 
part where the morbid secretion is produced, yet a variety of 
disorders are observed in all the different functions, for which 
no appreciable or satisfactory reason can be discovered. 
Sometimes the functions of the nervous system are those 
most disordered ; and the patient feels a general sense of lassi- 
tude and uneasiness, which is frequently considered as the re- 
sult of some nervous affection, or of hypochondriasis, until the 
local symptoms declare themselves, and remove all doubt as 
to the source of the disease. Sometimes the general symp- 
toms consist of slight febrile paroxysms, without any regularity 
either in their form, or in the periods at which they recur; 
and, lastly, we now and then observe an alteration in the gen- 
eral function of nutrition, producing a progressive emaciation 
that sometimes actually amounts to marasmus before the lesion 
Vol. I. 36 



274 LESIONS OF SECRETION. 

which causes it can be detected. Can there possibly exist a 
more striking example than this, of the wonderful depeudance 
and mutual connexion which subsists between the different 
organic actions by virtue of which the disturbance of any one, 
sooner or later induces the disturbance of the whole ? 

The local symptoms which proceed from the developement 
of an accidental production in an organ, consist either in the 
disturbance of its functions, or in the production of pain. This 
latter symptom does not constantly attend on any one of these 
morbid secretions ; neither does it afford a character by which 
any of them may, with any degree of certainty, be recognized ; 
in many cases it is wanting altogether. It is in all cases ne- 
cessary to distinguish between the symptoms which arise from 
the morbid secretion itself, and those which proceed from dif- 
ferent lesions of the tissue in which the production is developed. 
For instance, the symptoms local as well as general which ac- 
company the formation of a morbid secretion, when the sur- 
rounding parts retain their healthy structure, are widely dif- 
ferent from the symptoms which arise, when those parts are in 
a state of softening, sanguineous congestion, or purulent se- 
cretion. 

Many attempts have been made to investigate the causes 
which influence the formation of these morbid productions ; 
and, in order to explain their origin, three principal hypotheses 
have been formed. The partisans of one theory consider them 
all as the result of atony ; others, again, refer them to an in- 
creased degree of vitality, or in other words to a state of stim- 
ulus or irritation ; whilst a third party neither admit debility 
nor irritation as the essential elements of these productions, but 
attribute their formation simply to a modification, a kind of 
perversion of the natural actions of nutrition and secretion. 
The partisans of these three opinions each maintain that their 
doctrine is founded on the observation of facts, and appeal to 
experience in its confirmation. Thus, those who look upon 
such productions as the result of atony or debility, insist par- 
ticularly on the fact, that they are generally developed in per- 
sons of delicate constitutions, whose pale skin, and flaccid mus- 
cles, coupled with the circumstance of their blood containing 



LESIONS OP SECRETION. 275 

a deficient proportion of fibrine, announce a want of activity 
in all their vital functions ; they have likewise been forcibly 
struck with the fact of some of these accidental productions 
occurring especially under circumstances which tend to ener- 
vate the individuals submitted to their influence, and to impede 
their perfect developement. Thus it has been observed, that 
at the same time that, under the combined influence of a damp 
atmosphere, want of insolation, and insufficient or bad diet, 
the blood circulates in less quantity, or less highly coloured, in 
the capillary vessels of the cutaneous surface, and that the se- 
cretions of mucus and serum acquire an increased degree of 
activity, at the same period likewise tubercles are formed, and 
entozoary animals are developed in different parts of the body. 
No doubt can be entertained that in all this succession of 
morbid phenomena, there exists a diminution of the apparent 
strength of the individual, and a tendency to retrogade towards 
the organization of the inferior animals ; but in theory it may 
be objected, that this diminution of the powers of life exists 
only in certain organs, or in certain functions, and that in those 
parts where the tubercles or worms are developed, there exists 
a positive increase of the vital powers, or in other words a de- 
gree of irritation. To this objection it may be replied, that we 
cannot create these accidental productions artificially, even 
though we have recourse to every possible variety and degree 
of irritation, whilst, on the contrary, they spring up and multiply 
with almost incredible facility, wherever the debilitating effects 
of air and diet above alluded to come to exert their influence 
on the ceconomy. I shall not pretend to determine whether 
the parts in which the accidental productions are thus devel- 
oped, suffer a real diminution of their vital powers, such as we 
know from observation the parts engaged in the process of 
hsematosis undergo ; but it is an indisputable fact, that the 
blood which they receive under such circumstances is consid- 
erably modified in its qualities, and that in consequence of this 
modification, their nutrition and secretion must be also modi- 
fied. Thus far we are supported by facts. To maintain that 
in such cases the organic actions of nutrition and secretion 
are perverted, is a simple proposition stating what we know 



276 LESIONS OP SECRETION. 

from observation to take place ; but to maintain that these ac- 
tions are either exalted or diminished, is a mere assumption. 
It is, however, not to be denied, that the developement of a 
morbid production is frequently preceded by the most une- 
quivocal symptoms of irritation, or in other words, of the ex- 
altation of the vital powers of the parts affected ; but are we 
to suppose that this irritation is sufficientt of itself to explain 
the formation even of the simplest of these productions 1 In 
order to establish such a supposition, it would first of all be ne- 
cessary to demonstrate, that the formation of every accidental 
production corresponds with some determinate degree in the 
intensity or in the duration of the sanguineous congestion by 
which the existence of irritation is rendered sensible to us. 
Now it is notorious, that it is impossible to observe any such 
mutual correspondence, and that whether the congestion be 
intense or feeble, of long or of short duration, it is followed 
indifferently by the formation of various morbid productions, 
or else not succeeded by any one of them. Hence it is evi- 
dent, that though this congestion may be one of the conditions 
of the existence of these productions, it does not necessarily 
determine their formation ; and that in no case whatever can 
the peculiar nature of these productions be explained by this 
congestion alone. Besides, in a great number of cases, there 
is no proof whatever of any such congestion having ever 
existed ; and if, in the absence of any appreciable conges- 
tion, it be assumed that an irritation of secretion or nutri- 
tion exists, though in a latent form, I would ask, is not such 
a supposition the most gratuitous of all hypotheses ? If it 
be urged that we are authorized by analogy to admit the 
existence of such an irritation, I would reply that analogical 
reasoning is only admissible when supported by a rigorous 
induction, as for instance, when it is proved that the exist- 
ence of two facts cannot occur without the existence of a 
third ; in such a case, it is sufficient to perceive the first two, 
in order to affirm the presence of the other. How should the 
boasted improvements of modern science have ever been 
achieved, if from the frequent co-existence of two phenomena, 
their necessary and indissoluble connexion were inferred ? and 



LESIONS OF SECRETION. 277 

yet it is on a similar error of reasoning, that the doctrine is found- 
ed, which maintains that every morbid production is caused 
by an increase of vitality, or irritation, although its existence 
is in many cases disproved, both by theory and observation. 

Whatever tends to modify the natural process of inter- 
stitial secretion, tends likewise to create an accidental produc- 
tion ; it is only in this way that irritation operates as an ex- 
citing cause ; not because it increases the activity of the nu- 
tritrition or secretion, but because it deranges these organic 
functions. Any other cause which changes the natural mode 
of the nutrition or secretion of a part, is equally capable of 
generating these morbid productions. Whether it acts by 
exciting, or by debilitating, may be, and, no doubt, often is, an 
important consideration in determining the proper treatment 
to pursue, but has no influence whatever on the formation of 
the accidental product ; and if in some cases these produc- 
tions are formed in parts whose vital powers had previously 
assumed an unusual degree of activity, they are likewise to be 
found occurring where the activity of these powers is consid- 
erably diminished. Thus, melanosis, which is frequently 
formed in lungs that have long suffered from chronic irritation, 
is also found in the healthy lungs of old persons, which, we 
know from observation, have their anatomical elements re- 
duced to a state of comparative atrophy, and in reality possess 
a less degree of vitality than the lungs of children or of adults. 

There are in every individual, certain peculiarities of con- 
stitution, which lay the foundation of the different tempera- 
ments, and which, by imparting a peculiar character to the 
innervation, hasmatosis, and all the different functions of nutri- 
tion and secretion, are the real and essential cause of these 
morbid productions. These peculiarities may be independent 
of the primitive organization of the individual, and may have 
been acquired from the influence of external agents. Thus, for 
instance, the circumstance of living in a cold damp, atmos- 
phere from which the sun's rays are excluded, produces such 
a modification in the general state of the system, that a dispo- 
sition to the secretion of tubercles is formed in every organ ; 
thus, likewise, the same atmosphere causes an abundant de- 



278 LESIONS OF SECRETION. 

velopement of entozoary animals in the alimentary canal and 
in other parts of the body. A watery and not sufficiently nu- 
tritive diet, produces in sheep the worm known by the name 
of the Fluke {fasciola hepatica) ; and in man the use of food 
containing an excessive proportion of azote, produces a super- 
abundant secretion of uric acid, either in the kidneys, or in 
parts of the body where it is not usually formed. Independ- 
ently of the influence of these external agents, there are other 
causes which reside in the individual himself. Thus, as each • 
period of life produces some new modification in the cecono- 
my, different morbid secretions successively predominate : in 
childhood, for instance, tubercle is the most frequent of these 
secretions ; whereas in old age, melanosis is the most com- 
mon. 

The products of morbid secretion are numerous and of 
great variety : various attempts have accordingly been made 
to classify and distinguish them by names, but all that has as 
yet been effected towards the completion of this object, can 
only be considered as provisional. Thus, it could only have 
been until some more accurate knowledge was attained on the 
subject, that pathologists agreed to distinguish certain morbid 
productions from each other, by naming them, in some in- 
stances, after their form (tubercle), in others after their col- 
our (melanosis), and in others, after the resemblance they were 
supposed to bear to certain substances, such as glue (colloid 
matter), the substance of the brain (encephaloid matter), &c. 
It is evident that all these denominations belong to a science 
as yet in its infancy ; it is, however, necessary for the present 
to retain them, for if we attempt to substitute others in their 
stead, we shall experience considerable difficulty in the task, 
from the paucity of scientific data for the purpose. If, for in- 
stance, we endeavour to denominate them according to their 
chemical characters, we shall soon find how vain is the at- 
tempt ; for the most dissimilar of these productions present on 
analysis identically the same principles, albumen, fibrine, or 
some other animal substances which do not exactly answer to 
any of the immediate principles with which we are well ac- 
quainted. 



LESIONS OF SECRETION. 279 

Morbid secretions, whatever be their chemical or physical 
characters, may be divided into two principal classes, accord- 
ing as they do or do not present traces of organization and 
vitality. I think this division is a useful one to establish, inas- 
much as it fixes our attention on one of the most important 
phenomena of these productions. The following is the order 
in which they may be classified and described. 

In the first class, may be ranged all the products of morbid 
secretion in which no trace of organization or of vitality has as 
yet been discovered. 

These productions present every possible variety of consist- 
ence ; they may be either solid or fluid, or may even assume 
both these forms alternately : thus, the morbid product may at 
the time of its formation be fluid, and subsequently become 
solid, or may be at first solid, and afterwards fluid. The chem- 
ical analysis of these productions shews that they are princi- 
pally composed of albumen and gelatine ; they likewise con- 
tain certain salts. If we proceed to investigate their anatom- 
ical structure, we find that they present no trace of fibres, 
laminae, areolae, or canals ; in short, that they have none of 
those appearances which usually characterize organized bodies. 
The phenomena of vitality are never observed in these sub- 
stances, but only in the tissues amidst which they are formed, 
whether those tissues traverse their structure or merely invest 
their surface. It is in these tissues likewise that we are to 
look for the cause of those alterations which morbid produc- 
tions frequently undergo, as I have already endeavoured to 
prove, and as I shall again have occasion to explain when I 
come to treat of the softening of tubercles. 

The following are the products of morbid secretion which 
may be ranged under this first class : 

1. Pus. 

2. Tubercle. 

3. Colloid matter. 

4. Fatty matter. 

5. Colouring matter. 

6. Saline substances. 



280 LESIONS OF SECRETION. 

These several substances may either exist singly, or in va- 
rious states of combination. 

The second class of morbid secretions differs from the pre- 
ceding in presenting traces of organization, and exhibiting a 
certain number of vital actions. The substances comprised in 
this class appear principally composed of fibrine ; in several 
cases, however, the precise nature of the animal matter which 
forms their principal ingredient, is far from being well under- 
stood. 

The most simple of all these productions, and that which 
appears to be the original source whence many others are 
formed, is a fragment of pure fibrine, either coagulated in the 
blood-vessels, or extravasated into the surrounding tissues. 
This fibrinous deposit usually presents the appearance of a 
whitish or reddish mass, of variable consistence, and endowed 
with a certain tendency to become organized, though at first it 
possesses neither organization nor vitality. 

This mass of fibrine may, like the impregnated ovum, be- 
come the seat of various organic actions, which it reveals to us 
by the following phenomena. 1. By the constantly increasing 
tendency it has to assume the form of some one of the simple 
or compound textures which are found in the animal kingdom. 
2. By its performing different secretions. 3. By its exhibiting 
the same morbid phenomena when irritated, as the natural 
tissues do under similar circumstances. Hence it appears, 
that this fibrinous mass, like any other being endowed with 
life, possesses the faculties of absorbing, secreting, and nourish- 
ing itself, and is likewise susceptible of disease. 

These phenomena, which, wherever they are found, uni- 
formly indicate the existence of vitality, may take place in a 
morsel of fibrine, without its containing any organ properly so 
called, or even presenting any distinct or determinate texture. 
Its vitality in such cases may be compared to the imperfect 
life of those zoophytes that are composed merely of an amor- 
phous gelatinous mass, and, like the morsel of fibrine, perform 
the functions of nutrition, secretion, and absorption, although 
destitute of the slightest vestige of a circulatory apparatus. 
We are thus enabled to understand how a serous fluid may be 



LESIONS ON SECRETION. 281 

exhaled in the centre of a mass of coagulated fibrine, or be 
deposited in cells of various dimensions formed for its recep- 
tion ; and how pus, or any other species of morbid secretion 
may be developed in its interior. I have repeatedly found 
small collections of pus in the centre of those fibrinous coag- 
ula which are formed in the cavities of the heart, even in cases 
where there was no process of suppuration going forward in 
any part of the body, and where there consequently could 
have been no absorption of that fluid. I recollect once find- 
ing in one of these coagula, which was remarkable for its firm- 
ness, and adhered closely to the parietes of one of the auricles, 
a whitish substance resembling a mixture of plaster and water, 
such as is frequently found in the lungs. In the individual in 
whom this semi-calcareous concretion was found, (which ap- 
peared to me to result from a morbid secretion accomplished 
in the interior of the coagulum,) neither the lungs, nor indeed 
any of the other solids, contained any similar deposit. 

Several tumours, the origin of which has hitherto been mis- 
taken, may, I conceive, be fairly traced to the coagulation and 
solidification of fibrine in the blood-vessels of the part. The 
following examples will serve to illustrate my ideas on this 
subject. On dissecting the body of a middle aged man, I 
found one of the lungs full of masses of a whitish substance, 
like those which constitute the so called cancerous tumours of 
that organ. The pulmonary artery had its middle-sized rami- 
fications filled with a substance which in some points was solid, 
and of a dirty white or reddish colour, and in others was fluid, 
and in appearance similar to a thick greyish soup. 

This substance, when closely examined, appeared to me no- 
thing else than coagulated blood reduced to its fibrinous ele- 
ment, and retaining in some points its colouring matter, with 
the fibrine here and there in a state of fluidity. On pursuing 
my dissection, I ascertained the existence of a similar sub- 
stance in the more minute vessels, as far as I could follow 
them with the scalpel ; and in this way I fully satisfied myself 
that the whitish masses with which the lungs were studded, 
were neither a degeneration of the tissue of that organ, nor an 
accidental production developed in its substance, but simply an 
Vol. I. 37 



282 LESIONS OF SECRETION. 

assemblage of minute vessels filled with solid fibrine almost 
wholly deprived of its colouring matter. Neither was this the 
only case of the description which I have observed : I recollect 
finding a similar appearance in the liver ; and I am convinced 
that several of the tumours of that organ usually termed can- 
cerous, are in fact composed of solid fibrine accumulated in the 
minute ramifications of the veria porta?. I have likewise ob- 
served the same morbid appearance in the kidney: a fibrinous 
concretion of a dirty white colour, filled the emulgent vein, 
and adhered strongly to its parietes ; the coagulum was pro- 
longed into the subdivisions of the vein, and might be traced 
in its minutest ramifications even into those points where, 
before the dissection, nothing could be distinguished but 
masses of a dirty white or pale red colour, which Laenneo 
would have pronounced to be tncephaloid tissue in the state of 
crudity. If then this appearance may be produced by coag- 
ulated fibrine while contained in its vessels, we may a fortiori 
suppose that the same appearance may be produced by this 
same fibrine when escaped from its vessels, and collected into 
masses in the substance of an organ. In this manner, I con- 
ceive, are formed several of those morbid productions denom- 
inated by Laennec encephaloid tumours. 

We have already seen, that certain manifestly vital actions 
may take place in the fibrinous coagulum, even before it pre- 
sents any appreciable traces of organization, at least in the 
sense usually applied to that term. We are now about to 
view it presenting other phenomena, which, in their successive 
developement, bear a striking analogy to the several metamor- 
phoses of the embryo, from the first moment of its impregna- 
tion, to the time when it becomes a perfect animal, capable of 
enjoying an independent existence. The first symptom of an 
approach towards organization which we can detect in the 
morbid production, is the formation of red points, such as are 
observed in the vitellary membrane of the chicken ; from 
which it would appear that the chemical elements of this mor- 
bid production have the same tendency as those of the im- 
pregnated ovum, to form such combinations as shall produce a 
colouring matter similar to that of the blood. In some cases, 



LESIONS OF SECRETION. 283 

few red points like small collections of blood, scattered on 
the surface or in the interior of a whitish mass, constitute the 
whole appearance of organization. In others, again, we ob- 
serve reddish lines or furrows, of various lengths, and running 
in various directions: these rudiments of vessels are sometimes 
isolated from each other, and sometimes anastomose, forming 
by their mutual intersections a sort of net-work with meshes 
of various sizes. Lastly, in other instances, we are able to 
detect the existence of regular blood-vessels, and may even 
detach them from the substance of the mass in which they are 
formed, which could not be done in the preceding case : they 
are in general exceedingly delicate. As their developement 
proceeds, some of the branches of this independent circulatory 
system, which at its commencement was as perfectly uncon- 
nected and isolated as that of the membrane of the yolk in the 
egg, gradually elongate themselves so as to anastomose and 
communicate with the vessels of the adjacent tissues. 

It sometimes happens, that instead of finding in these pro- 
ducts of morbid secretion a system of vessels more or less per- 
fectly developed, we can discover no trace of vascularity 
whatever ; but in the centre of the mass a collection of fluid 
blood is found, just like those collections of pus and serum, 
which we have already noticed as not unfrequently met with 
in the centre of fibrinous coagula. Indeed these effusions of 
blood are by no means uncommon ; thus presenting the 
curious phenomenon of blood without blood vessels. We 
must carefully distinguish from the above description, those 
cases in which a real haemorrhage occurs ; that is to say, in 
which the blood escapes from vessels that are visible on in- 
spection of the part. The extreme delicacy of their parietes 
of course renders these vessels peculiarly liable to rupture. 

When once vessels are forme d in a morbid production, or 
even when currents of blood are established, though no distinct 
vessels are as yet formed,* the substance which had previously 



* The researches recently made by Dr. Dollinger in Germany, fully confirm 
the results previously obtained by other anatomists. It appears to me now fully 



284 



LESIONS OF SECUETIO.V. 



been an amorphous mass, tends to lose its homogeneous nature, 
and to assume a particular texture. Its anatomical elements 
arrange themselves either in fibres, lamina?, cells, or net- works; 
and in this way the morbid secretion may assume the structure 
and appearance of the natural tissues, with the exception of 
the nervous and the muscular. 

The morbid productions capable of becoming organized and 
of being endowed with vitality, may be formed in every part 
of the body where there is blood, being nothing but modifica- 
tions of the fibrinous element of that fluid. They have even 
been found in the vessels themselves, from the largest to the 
smallest ; indeed it is in them that we can most accurately 
trace the several stages of the various transformations the fib- 
rine undergoes, from its simple coagulation, until it arrives at 



demonstrated, that currents of blood may be established in animal substances 
when about to undergo the process of organization, even though there exist no 
distinct tubes or vessels for the passage of the fluid. In several of the inferior 
animals, the blood or other fluid which serves as a subtitute, is not contained in 
any regular vessels, but traces out a passage for itself through the solids ; and 
even in the highr order of animals, there exist currents of blood which traverse 
the substance of the different organs, independently of any apparatus of vessels. 
It is exceedingly curious to observe, in the intimate structure of the different 
tissues, globules of blood detaching themselves either from the solid substance of 
the part, or from other globules in motion, and, after moving about in different 
directions, losing themselves in other currents with which they come in contact, 
or else attaching themselves to the solid substance of the tissue ; so that in fact 
the/ state of motion or of repose constitutes the only difference that exists be- 
tween this solid substance and the blood. A tissue is animal matter in the state 
of repose ; the blood is the same animal matter in a state of motion. As to the 
force which produces this motion, we in fact know nothing ; for it surely cannot 
be considered a satisfactory explanation to attribute it to vitality. As well might 
we say, that the heavenly bodies are endowed with vitality because they move. 
If I were to hazard an hypothesis on the subject, I should feel disposed to admit 
the agency of electricity in producing this passage of animal matter from a state 
of rest into a state of motion. In fact, in the living body there are several causes 
constantly operating, which must tend to generate electricity, such as the con- 
tinual friction which takes place, and the universal presence of heterogeneous 
substances, &c. 

These facts might serve to prove the possibility of currents of blood traversing 
certain morbid productions, even though their existence was not established by 
direct observation. 



LESIONS OF SECRETION. 285 

that state in which it generates its own vessels, and produces 
in its interior various morbid secretions. The blood that es- 
capes from a wounded vessel has frequently been observed 
coagulating in the surrounding cellular tissue, and there assum- 
ing unequivocal appearances of organization : Hunter succeed- 
ed in injecting the vessels which were formed in a clot of blood, 
and the same experiment has since been successfully repeated 
by Sir Everard Home. 

It is not, however, only in those cases where a vessel has 
suffered a solution of continuity, that the fibrine may thus make 
its escape into the surrounding cellular tissue, and there be- 
come organized ; for, it not unfrequently happens, that, under 
the influence of certain causes more or less appreciable, the 
fibrine, either alone or accompanied with a variable proportion 
of the colouring matter, abandons the other elements of the 
blood, and, escaping from the vessels by some morbid process, 
finds its way into the adjacent tissues. This separation of the 
fibrine independently of any rupture of the vessels, may be 
proved to demonstration in the cavities lined with serous mem- 
branes ; for we shall presently see that the organizable matter 
which is exhaled on the free surface of those membranes in 
cases of peritonitis, pleuritis, &c, has been ascertained by 
chemical analysis to consist exclusively of fibrine. The plas- 
tic substance, known by the name of coagulable lymph, which 
is formed wherever there has been a solution of continuity, is 
likewise composed of pure fibrine. Arguing then from analogy, 
I am disposed to think, that this principle likewise constitutes 
the basis of all those morbid productions that present traces of 
organization, whether developed in parenchymatous or in 
membranous tissues. In the present state of our chemical 
knowledge, it is in some cases exceedingly difficult, if not alto- 
gether impossible, to distinguish fibrine from albumen ; it has 
even been said that albumen, when solidified, gradually assumes 
the characters of fibrine ; and that the albumen of the chyle 
approaches nearer the appearance of fibrine, as it is examined 
nearer to the thoracic duct. Our anatomical knowledge on 
this subject must, therefore, remain uncertain, as the chemical 



286 



LESIONS OF SECRETION. 



data on which it is founded are themselves involved in consider- 
able uncertainty. 

All the morbid productions we have as yet considered par- 
ticipate in the life of the rest of the body, and adhere to and 
communicate with it either by vessels, or by some other me- 
dium of connexion. But there are other productions that have 
no connexion whatever with the surrounding tissues. To this 
this class may be referred, in the first place, certain fibrinous 
concretions, which though floating loose in the fluid of a serous 
cavity, present evident marks of incipient organization. Be- 
clard used to exhibit specimens of this description at his lec- 
tures, and I have myself seen several instances of it. Instead 
of these floculent masses, which present traces of organization 
before assuming any determinate form, we sometimes find 
transparent cysts, containing in their interior a serous fluid 
similar to that in which they float. The most remarkable case 
of this description I have seen, was in a monkey, which I ex- 
amined with M. Magendie in 1818. On opening the body, I 
found one of the pleurce filled with a large quantity of serous 
effusion, in which there floated nearly 40 spherical bodies, 
each about the size of a hazel nut. These little cysts possessed 
a considerable degree of elasticity ; their parietes were colour- 
less and transparent, and were composed of a homogeneous 
tissue, like serous tissue, smooth on both surfaces, and present- 
ing no appearance of granulations. The fluid which they 
contained was perfectly limpid. Cysts of this description are 
much more frequently met with in accidental serous cavities, 
in which situation they often exist in considerable numbers, and 
are contained one within the other. The texture of their pari- 
etes does not always possess the density or firmness of the 
natural serous membranes ; and in some cases they seem com- 
posed merely of a sort of gelatinous substance, which is easily 
broken down under the finger like size, or else bears a striking 
resemblance to the tissue of the transparent cornea, when soft- 
ened by prolonged maceration. This substance is not always 
found in the rounded form of a cyst ; it sometimes presents the 
appearance of filaments, or of an irregular web suspended in 
a serous or other fluid : hence it appears, that at the first pe- 



LESIONS OF SECRETION. 287 

riod of its developement in the medium in which it is suspend- 
ed, it possesses no determinate shape ; and that it subsequently 
assumes the form of a cyst, just in the same manner as the co- 
agulum of fibrine, which is originally an amorphous mass, after- 
wards becomes vascular and organized. But there is yet an- 
other class of these morbid productions, which present a still 
higher degree of organization : in the place of simple cysts, 
floating in different fluids, whether natural or accidental, we 
sometimes find bodies possessing a more complicated structure, 
which, in addition to a vesicle filled with an aqueous fluid, are 
furnished with other parts, that from their form and situation 
give to these vesicular bodies the appearance of animals. 
Thus, an appendage similar to a head is not unfrequently at- 
tached to these vesicles, from which it can be protruded and 
retracted. This head may be either single or compound ; and 
occasionally presents several orifices, which seem in some in- 
stances to serve as suckers, and in others as organs of progres- 
sion. The vesicular, next passes gradually into the cylindrical 
or flattened form, and the characters of animal life become 
much better marked, by the manifestation of unequivocal 
movements, and by the appearance of different organs as dis- 
tinct and as well formed as those of the vertebrated animals. 
In this way we pass by regular and almost insensible grada- 
tions from the simple clot of fibrine deposited in a serous cav- 
ity, to the strongylus or the ascaris lumbricoides ; just as during 
the formation of the embryo, we observe it gradually advanc- 
ing from the state in which it exists as a homogeneous mass, 
devoid of form or texture, until it acquires all the organs of a 
perfect animal ; and as, in the series of animated nature, we 
can trace the developement and progress of life and organiza- 
tion, from the green matter of vegetables up to man. It ap- 
pears to me perfectly futile to attempt fixing the point in this 
series of transformations where what is called animal life com- 
mences. If we give the name of animal to the cyst which 
floats loose in a serous cavity (the acephalocyst of Laennec), 
why should we refuse it to the clot of fibrine, which, like the 
cyst, floats loose in a serous cavity, and is moreover provided 
with vessels ? and if we consent to admit the animal existence 



288 LESIONS OF SECRETION. 

of this clot of fibrine, where are we to stop, or where draw 
the line of demarcation ? If we admit to the rank of animal 
every aggregate of matter which, being developed in the inte- 
rior of a being endowed with life, is capable of supporting 
itself, and of increasing in size without having any connexion 
with that being, the serous cysts already described must then 
be considered as animals, and accordingly they have been de- 
scribed as such by Laennec. But if we only recognise as 
animals those bodies which present some trace ef sensibility 
or motility,* these cysts then forfeit all claims to that title. So 
that, in fact, this much agitated question turns out to be a mere 
dispute of words, which can never be finally adjusted until the 
contending parties shall agree in their definition of what it is 
which essentially constitutes an animal. 

I have now enumerated the principal varieties of form, tex- 
ture, and situation, which organizable morbid productions are 
capable of assuming. When developed on the free surface of 
the different membranes, they constitute the false membranes, 
and when formed in the cellular tissue, either where it exists 
free and uncombined with other tissues, or where it enters 
into the structure of the parenchymatous organs, they consti- 
tute a class of the morbid productions which differ much less 
from the false membranes in their nature and properties, than 
in the form they are compelled to assume in consequence of 
the situation in which they are developed. Like the false 
membranes, they present considerable varieties of appearance, 
depending especially on their consistence, colour and different 
degrees of vascularity ; to each of which if we attach a par- 



* Some authors have gone so far as to represent the globules of the blood as so 
many animalculi, simply because during their circulation they execute some re- 
markable movements. It yet, however, remains to be proved, that these move- 
ments are spontaneous; and I confess I think it much more probable that they 
are merely the result of some external force of the nature of electricity. If this 
force, whatever it be, could be rendered inherent in the globule itself, it would 
then become an animal ; but so long as its movements are dependant on an ex- 
ternal force, it is evident that it can have no claims to that rank ; the power of 
spontaneous motion, and not any particular/orm or structure, seeming to be the 
true requisite for that purpose. 



LESIONS OF SECRETION. 289 

ticular name, we may multiply ad infinitum the number of 
species and varieties of these productions. But in thus de- 
scribing each variety of appearance which these bodies are 
capable of assuming, and erecting each into a distinct species 
(as Laennec did with that particular variety which he denomi- 
nated encephaloid matter) there is, in my opinion, nothing phi- 
losophical, or calculated to advance the interests of science. 
For, after all, of what consequence are these distinctions ? In 
a practical point of view, all that is really important is to know 
that, notwithstanding the varfeties of appearance which they 
assume, they are all identically of the same nature ; that they 
have all a constant tendency to the developement of organiza- 
tion ; that, in all of them, the essential phenomena of life, 
namely, nutrition, secretion, and absorption, may take place ; 
and finally, that in such as contain blood, hyperaemias may be 
formed, and that in those which are capable of secreting, the 
various morbid secretions, such as pus, tubercle, &c. may be 
developed. 

All the varieties of morbid productions susceptible of life 
and organization may, I conceive, be reduced to two classes. 

The first class comprehends such of these products as par- 
ticipate in a common life with the rest of the body, on which 
they have the same dependance as the natural organs, and 
with which they are, like those organs, continuous, having, in 
short, the same physical relations to it as any individual organ. 
They may either be deposited on a surface, or else developed 
in the substance of a tissue or organ. 

The second class comprehends all the entozoa, that is to 
say, the different morbid productions developed in the living 
body which have an individual existence, like that of an 
animal. Indeed most of these productions are as perfect 
animals as many which have a determinate place assigned 
them in the zoological scale. 

The following classification of the products of morbid secre- 
tion, founded on these principles, appears to me the most 
philosophical, and best adapted to the present state of science. 
We must still, however, bear in mind that, like the rest, it is 
merely provisional. 

Vol. I. 38 



290 LESIONS OF SECRETION. 

First Class. 
Morbid secretions not capable of becoming organized. 

First Genus. 

Substances of an albuminous appearance. 
Pus. Tubercle. 

Second Genus. 

Substances of a gelatinous appearance. Type: the colloid 
substance of Laennec. 

Third Genus. 
Fatty Substances. 

Fourth Genus. 
Saline substances. 

Fifth Genus. 
Colouring substances. 

Second Class. 
Morbid secretions capable of becoming organized. 

First Genus. 

Organizable matter deposited on the surface of organs. 
Ascertained chemical element : fibrine. 
Generic term : false membranes. 

Second Genus. 

Organizable matter deposited in the substance of organs. 
Probable chemical element ; fibrine. 



LESIONS OF SECRETION. 291 

* Scirrhus. 
L Simple Sarcoma. 

Different appellations by which it has been " Z [esh l s ^< Dm 

j • , -i J \ Vascular sarcoma. 

designated . \ Medullary sarcoma. 

r Encephaloid. 

^ Funsrus Ffematodes. 



Third Class. 

Organized products possessing an independent vitality. 

Chemical elements : like those of all animals, complex. 

Generic term : entozoa. 

In this order I shall now proceed to describe the different 
morbid secretions. Some of them, however, I shall notice 
but slightly, either in consequence of their small importance, 
or because we as yet know but little about them ; more ac- 
curate researches on the subject being still amongst the 
desiderata in the science. 



292 LESIONS OF SECRETION. 



FIRST CLASS. 

MORBID SECRETIONS NOT SUSCEPTIBLE OF ORGANIZATION. 

FIRST GENUS. 

SUBSTANCES OF AN ALBUMINOUS APPEARANCE. 

FIRST SPECIES. 



The generic term, pus, has long been applied to a morbid 
secretion, which occasionally presents considerable varieties 
in its physical properties. A homogeneous creamy fluid, of a 
yellow white colour, sweetish taste, and faint smell, consti- 
tues what, by way of pre-eminence, has been called laudable 
pus. In several instances, however, its appearance varies 
considerably from this description ; as it sometimes resembles 
a turbid serum or sanies, and sometimes assumes a grumous 
appearance, or even evinces a disposition to become solid, and 
to assume the appearance of the accidental production known 
by the name of tubercle. Nay, the pus which is secreted from 
the same surface, may, in a short space of time, so completely 
alter its physical properties, as to resemble alternately a thick 
cream, a mixture of curds and whey, and the dregs of wine ; 
its colour too may change alternately from white to yellow, 
green, or red ; and its smell may be at one time inodorous, 
and at another more or less foetid. 

Several varieties of pus have been established, founded on 
these alterations of its physical properties. Pearson has en- 
umerated no fewer than four, to which a fifth has been added 
by other authors. 

1st Variety. — Creamy homogeneous pus. 

2nd Variety. — Curdy pus. 

3d Variety. — Serous pus. 

4th Variety. — Glairy muciform pus. 



LESIONS OF SECRETION. 



'293 



The third of these varieties is likewise known by the name of 
sero-purulent fluid, and the fourth, by the term puriform mucus. 
The fifth variety is distinguished by the name of concrete or 
lardaceous pus. 

These fluids, though presenting such remarkable differences 
in their physical properties, appear perfectly identical when 
examined with a microscope ; as they then all seem composed 
of globules floating in- a fluid, which resembles the serum of the 
blood in being coagulable by heat and acids, but differs from 
it in being likewise coagulable by muriate of ammonia. The 
globules of pus have been considered by many authors as pre- 
cisely similar to the globules of the blood, when deprived of 
their envelope of colouring matter. According to M. Gen- 
drin,* these globules only differ from ihose of the blood in 
being somewhat larger, and of an opaque yellow colour ; and 
these differences, he conceives, depend on the transformations 
which the globules of the blood undergo during its conversion 
into pus. According to this ingenious author, the whole pro- 
cess of the transformation of the one fluid into the other may 
be observed with a microscope, in that species of pus known by 
authors under the name of bloody pus. In the first stage of 
the process, the globules of the blood are seen divesting them- 
selves of their colouring envelope, which appears in striae in 
the intervals between them. They are then much paler than 
natural, of a greyish red colour, and still transparent: they 
next become opaque, and of a greyish yellow colour ; in this 
state the globules may be considered as semipurulent : lastly, 
these globules become larger than those of the blood or of its 
coagulable matter, and assume a wrinkled appearance after 
remaining a few moments on the object glass of the micros- 
cope ; which marks the completion of their transformation into 
globules of pus. According to this statement, the only differ- 
ence between pus and blood would appear to be, that the 
globules of the latter, during its conversion into the former, un- 
dergo certain modifications in their size and colour. On the 



* Histoire Anatomique des Inflammations, torn. ii. page 489. 



294 LESIONS OF SECRETION. 

other hand, Doctors Hodgkin and Lyster, who have recently 
bestowed considerable attention on this subject, are of opinion 
that the globules of pus have not the slightest resemblance 
whatever to those of the blood, and are extremely irregular in 
their form and size. I shall not at present attempt to recon- 
cile these discrepancies of opinion, or to decide which is the 
most probably correct. I am, however, of opinion that the 
different varieties of appearance which. pus presents, depend 
on certain modifications both of the globules, and of the fluid 
in which they are suspended. These modifications may either 
affect their quantity or their quality. When the globules exist 
in great abundance, the pus is thick and opaque ; on the con- 
trary, it becomes more and more serous as the proportion of 
globules diminishes. The grumous concrete state of the pus 
may either proceed from an alteration in its fluid part, which 
becomes spontaneously coagulable, or from an excessive pro- 
portion of globules. It is evident that, if we suppose these 
globules to be identical with the globules of the blood, we 
must admit that beside the modifications which they undergo 
in their form, size, and colour, they have likewise lost their 
faculty of plasticity or organization. 

Pus has repeatedly been submitted to chemical analysis. 
Schwilgue found it composed of albumen in a particular state, 
attractive matter, fatty matter, soda, muriate of soda, phos- 
phate of lime, and other salts. According to this analysis, the 
only difference between the serum of the blood and pus con- 
sists in the presence in the latter fluid of extractive matter, and 
in the particular state of the albumen. The nature of the ex- 
tractive matter has not as yet been satisfactorily determined : 
by some chemists it has been regarded as a peculiar animal 
substance, to which nothing analogous can be detected in the 
healthy state ; by others as a combination of albumen and 
fibrine ; whilst a third set consider it as a peculiar modification 
of fibrine, rendered incapable of coagulating spontaneously or 
of being organized. Pearson denominates this matter an ani- 
mal oxide, and assigns as its physical characters, that it is 
white, opaque, and sparingly soluble. Lastly, some authors 
are of opinion that this peculiar substance presents a consider- 



LESIONS OF SECRETION. 295 

able analogy to the caseum of milk. If this latter opinion 
should turn out to be correct, it may afford some explanation 
of the peculiar tendency to suppuration which females mani- 
fest after child-birth. According to M. Gendrin, the pus fur- 
nished by scrofulous ulcers contains a larger proportion of soda 
and muriate of soda ; to which cause he attributes its remark- 
able fluidity. Cruikshank analyzed the foetid ichorous pus 
which is discharged from hospital gangrene, and found it com- 
posed of precisely the same elements as those already enume- 
rated. 

When pus is poured into water, it subsides, and forms a pre- 
cipitate at the bottom of the vessel ; but if the mixture be 
shaken, the water assumes a uniform white colour. When lit- 
mus paper is introduced into pus, it is in some cases turned 
red, in others restored to blue, and in others its colour is in no 
ways affected, especially if the pus has been recently taken 
from an acute phlegmonous abscess in a state of healthy sup- 
puration. The pus which is formed in scrofulous individuals 
appears to be in general alkaline ; and lastly, this fluid becomes 
acid whenever it has been exposed for any time to the action 
of the atmosphere. According to some chemists, a solution of 
caustic potash, poured on pus, does not dissolve it, but converts 
it into a viscid, ropy, semi-transparent substance, which re- 
mains suspended in water without mixing with it. Thompson* 
has remarked that pus, when thus altered by the action of al- 
kalies, presents a striking resemblance to the mucus which is 
secreted in diseases of the bladder. Other authors, however, 
amongst whom is M. Gendrin, maintain that pus is dissolved 
by a solution of caustic potash, and may be precipitated from 
the solution by the addition of water. These opposite results 
in all probability proceed from the same kind of fluid not hav- 
ing been employed by the different experimenters. Ammonia, 
when applied to pus in a concentrated form, converts it into a 
transparent colourless jelly, possessing a remarkable degree of 
tenacity. It has been stated, that when pus is treated with 



* Traite de l'Inflammation traduit par Bouisseau et Jourdan. 



29G LESIONS OF SECRETION. 

sulphuric acid, it forms a reddish solution, from which it may 
be precipitated by the addition of water. The following are 
the results of my experiments on this subject. I mixed with 
the sulphuric acid of commerce, 1. softened tubercular matter ; 
2. creamy pus collected from cavities in the lungs of individu- 
als who had died of phthisis ; 3. pus furnished by a pleuritic 
effusion ; 4. the sputa of persons in the last stage of consump- 
tion ; 5. the sputa of patients labouring under chronic pulmo- 
nary catarrh ; 6. mucus collected from the pharynx and from 
the nasal fossae. All these different fluids were alike dissolved 
by the acid, which, in every instance, turned at first red, and 
afterwards black, this latter change being accompanied with a 
considerable elevation of temperature. When a small quan- 
tity of water was poured into these solutions, they assumed a 
greyish white colour, and if a little more were added, a gru- 
mous, curdy deposit was observed gradually forming in large 
quantities ; and when, after some hours, it had completely sub- 
sided, the rest of the fluid became transparent and colourless. 
I could not, in any of these experiments, verify the remark of 
Darwin, that pus forms a greyish sediment at the bottom of 
the vessel, and that mucus, on the contrary, remains suspended 
in the form of minute flocculi. Darwin also announced, that 
nitric acid dissolves both pus and mucus ; and that if water be 
added to the solutions, the pus is precipitated, and the fluid in 
which it had been dissolved remains transparent ; whereas the 
mucus is not precipitated, but the solution becomes turbid and 
dirty. These observations do not at all coincide with the re- 
sults obtained in my experiments ; for I constantly found, that, 
on the addition of the nitric acid of commerce to the fluids 
above enumerated, so far were they from being dissolved, that 
they invariably acquired a greater degree of consistence, and 
remained suspended, in the form of yellow grumous masses, 
without depriving the medium of its trasparency. The results 
obtained by Beaumes,* are exactly the same as those I have 
stated as observed by myself. I shall not dwell longer on this 



* Traits de la Phthisie Pulmonaire, torn. i. 



LESIONS OF SECRETION. 297 

subject, for no useful object that I am aware of has as yet 
been attained by the attempts made to ascertain the effects of 
the various reagents on pus ; neither have chemists been more 
successful in the distinctions they endeavoured to establish be- 
tween pus and mucus. No doubt, in certain cases, a well 
marked difference must exist between them ; the fluid which 
is furnished by a healthy mucous membrane is, doubtless, 
widely different, and may be readily distinguished by its chem- 
ical characters from pus furnished by an acute phlegmonous 
abscess : but is that the case with the mucus secreted by a dis- 
eased membrane, which presents as many varieties in its com- 
position as there are different degrees or modes of irritation 
in the membrane that furnishes it ? The fact is, that in this 
case pus and mucus alternately run into each other, so that no 
precise line of demarcation can be drawn between them. 
The importance attached to this distinction must have been 
much greater at a period when it was universally believed that 
pus could only be formed by a tissue in a state of ulceration ; 
for then, to detect the presence of pus in the sputa, would 
have been considered tantamount to proving the existence of 
an abscess in the lungs. But what practical advantage can we 
of the present day expect to derive from the discovery of such 
means as should enable us to distinguish with certainty be- 
tween these fluids, when we know that the mucous membrane 
of the bronchia, in a state of chronic irritation, may furnish all 
the varieties of secretion which are formed in a pulmonary ex- 
cavation. 

Not only does pus present considerable varieties in its physic- 
al and chemical properties, but two portions of this fluid 
which, in their external appearance, present not the slightest, 
difference, and in their chemical characters are perfectly iden- 
tical, may nevertheless differ so widely from each other, that 
one of them applied to a mucous membrane, or introduced under 
the epidermis, shall determine only a local irritation of various 
characters and degrees of intensity, whilst the other shall pro- 
duce either syphilis or small pox. 

It is interesting to observe the different circumstances which 
contribute to modify the physical properties of pus, and cause 

Vol. L 39 



298 LESIONS OF SECRETION. 

it to assume, either temporarily or permanently, one or other 
of the appearances we have already enumerated. In many 
cases, for instance, an alteration, so slight as to be scarcely per- 
ceptible, in the process of irritation of a suppurating sore is 
sufficient to convert its thick white pus into a reddish sanies, 
or to re-convert the ichorous discharge into what is termed 
laudahle pus. In order to obtain these results, it is in some 
cases necessary to diminish the irritation, and in others to in- 
crease its activity. We are not, however, to suppose that the 
qualities of the purulent secretion are affected by these local 
conditions only ; they are likewise modified by every altera- 
tion, whether physiological or pathological, which takes place 
in any other organ, no matter how far removed from the seat 
of suppuration, even though it has with it no particular c6n- 
nexion either of function or tissue. Thus, we have all seen 
instances of the pus secreted by the surface of a sore becoming 
suddenly altered, both in quantity and quality, under the influ- 
ence of a simple moral emotion, of the process of digestion, of 
the diminution or increase (whether spontaneous or artificial) 
of any of the secretions ; or, in short, of any supervening dis- 
ease. Nay further, there are certain constitutions, certain 
idiosyncrasies, which modify the qualities of pus, and in which 
it constantly assumes a peculiar and determinate character. 
There are some persons, for example, whose organs when irri- 
tated, never furnish any other secretion than a thin serous 
fluid ; in others it is always blood more or less pure which is 
secreted ; whilst, in a third class of persons, the place of pus 
is supplied by a grumous fluid presenting the appearance of 
fragments of cheesy matter floating in an albuminous fluid. 
This peculiar modification of the purulent secretion is chiefly 
observed in scorbutic and scrofulous individuals, in whom all 
attempts to modify the qualities of the suppuration by local 
treatment are utterly ineffectual ; | for it is the system at large, 
and not merely the suppurating surface, which is deranged in 
its nutrition and secretion. If, then, we wish to alter the qual- 
ities of the pus formed in scrofulous or scorbutic persons, we 
must commence by endeavouring to modify their whole pro- 
cess of nutrition, innervation, and hocmatosis. 



LESIONS OF SECRETION. 299 

Various hypotheses have been formed in order to explain 
the origin and formation of pus. It is the more unnecessary 
to repeat them here, as this fluid is now almost universally re- 
garded as the product of a morbid secretion which takes place 
in the solids, when irritated in a certain manner and within 
certain limits. (I shall presently discuss the point, whether 
the formation of pus is in all cases necessarily preceded by irri- 
tation.) In the valuable work lately published by Doctor Gen- 
drin, the author endeavours to prove that pus is nothing more 
than blood in a peculiar state of alteration, and that the glob- 
ules of the blood escape from the capillaries in the state of 
pus, in consequence of some modification they are subjected 
to, during the stagnation which the blood undergoes in certain 
degrees of active hyperemia. The following are the facts 
which he adduces in support of his opinion. 

1. If we examine with a microscope a portion of cellular 
tissue in which we can perceive with the naked eye a mixture 
of bloody serum and pus, we observe at the point most remote 
from that where the pus exists, a transparent fluid destitute of 
globules ; a little nearer the seat of suppuration we begin to ob- 
serve in the same fluid globules exactly similar to those of the 
blood ; as we approach the suppurating point, the globules 
change their appearance, they gradually lose their trans- 
parency, and in the seat of suppuration become perfectly 
opaque. In this experiment then, we can trace the first ap- 
pearance of fibrinous globules in a serous fluid, and their sub- 
sequent transformation into purulent globules. 

2. If a seton be passed through a portion of artery previous- 
ly obliterated by coagulated fibrine, the fibrine is thereby 
thrown into a state, of suppuration ; it becomes soft, and is 
gradually converted into pus. The same conversion may be 
observed around grains of lead or mercury which have been 
introduced into a portion of artery previously emptied of its 
blood. A coagulable substance ere long obliterates the vessel, 
and subsequently becomes soft and is converted into pus round 
the foreign body. 

3. If a solution of nitrate of silver, or of caustic potash, be 
injected into an artery or vein, the circulation having been 



300 LESIONS OF SECRETION. 

previously suspended ; and if, after the injection, the blood is 
allowed to flow into the vessel, and there retained by a double 
ligature, we observe it first coagulating, and then losing its red 
colour, and passing progressively into pus. 

4. If we irritate the foot or mesentery of a frog, and observe 
with a microscope the modifications which the circulation in 
these parts undergoes, we perceive the blood, (as has been 
more fully explained at the commencement of this volume,) 
circulating more quickly in some points ; but in others its 
course becomes progressively slower, and in these parts the 
eye can follow the various alterations which the globules of the 
blood undergo during their conversion into pus : they are first 
seen corrugating themselves, for the purpose of getting rid of 
their colouring envelope ; they then gradually lose their trans- 
parency, and arrive at the edge of the solution of continuity, 
where the irritation is strongest, transformed into purulent 
globules. 

These experiments require to be repeated ; for it is possible 
that their ingenious author may have been deceived by the re- 
semblance of colour, and may have mistaken for the globules 
of pus what in reality were only the globules of the blood de- 
prived of colour. I do not, however, by any means wish to 
reject, without farther examination, the idea of pus being sim- 
ply the fibrine of the blood which has undergone certain mod- 
ifications caused by derangements in the circulation. Such 
an idea I conceive to be too important, and fraught with too 
serious consequences to be hastily rejected ; but for the same 
reason also I should be slow in adopting it as an established 
fact, until its accuracy is fully demonstrated by additional facts 
and experiments. 

Pus has been found in every tissue in the body, and even in 
the blood itself, of which I have already related some exam- 
ples. Collections of pus are particularly frequent in certain 
portions of the cellular tissue, especially in the subcutaneons 
and intermuscular tissue. They are seldom met with in the 
submucous cellular tissue ; I have, however, occasionally 
found small abscesses in that portion which lines the mucous 
membrane of the alimentary canal, and in one case I recol- 



LESIONS OF SECRETION. 301 

lect finding an extensive layer of pus interposed between the 
mucous and muscular coats of the stomach, throughout the 
whole extent of that viscus. Of all the different portions of 
the subserous cellular tissue, that in which pus is most fre- 
quently found, is the part which, under the name of pia mater, 
is in contact with the adherent surface of the arachnoid : 
sometimes the purulent infiltration of the pia mater is limited 
to certain points ; in other cases it is general, as when it forms 
a vast envelope round the entire surface of the brain and spinal 
cord, of which some examples are on record. 

In all the other serous membranes it is much more common 
to find pus effused into their cavities, than deposited on their 
external surface. Why is it, that the arachnoid differs from 
all the other serous membranes in this respect ? 

It is now generally admitted, that mucous membranes are 
capable of secreting genuine pus, the mucus which in the nat- 
ural state lubricates their surface passing into it by insensible 
degrees. 

Pus has repeatedly been found in the vascular system ; 
its presence has been ascertained particularly in the s following 
places : 

1. In the veins which returned the blood from parts where 
there was a collection of that fluid. In several cases of 
metritis, for example, terminating in suppuration, the uterine, 
hypogastric and iliac veins, and the inferior vena cava, have 
been found full of pus. 

2. In veins that had been irritated by a puncture or other- 
wise, independently of the existence of any abscess or collection 
of pus. In such cases the pus is evidently formed in the inte- 
rior of the vein. 

3. In the coagula of blood which are formed in the heart 
and large vessels, whether there had existed at the same time 
a purulent collection in some other part of the body, or an old 
discharge of pus had ceased a short time previous to death, or 
even though no trace of suppuration could be detected during 
life, or after death. 

4. In the lymphatic vessels. In some cases these vessels set 
out from a part in a state of suppuration ; but in others there 



302 LESIONS OF SECRETION. 

was no pus to be found except in the lymphatic vessel itself. I 
have sometimes found the lymphatics leading from an intestinal 
ulcer, laden with pus, either fluid, or in a semi-concreted state, 
and in this latter form bearing a strong resemblance to the mat- 
ter of tubercle. 

A great deal has been said of the peculiarities of the pus fur- 
nished by the osseous tissue. I am inclined to think, however, 
that in the greater number of cases this pus is not furnished by 
the bone itself, but by the surrounding soft parts. The peculiar 
smell and colour, as well as the different physical qualities on 
which so much stress has been laid, appear to me to depend 
principally on the condition of these parts, on the exposure of 
the purulent collection to the atmosphere, either directly or 
through the medium of a fistulous passage, and also on the na- 
ture of the applications used for dressings, &c. 

The pus of the muscular tissue is, in reality, furnished by the 
cellular tissue interposed between its fibres. 

It is a question which yet remains to be decided, whether, 
when the nervous tissue is in a state of suppuration, the pus is 
furnished»by the nervous tissue itself, or by the cellular tissue 
which enters into its composition. This much, however, is cer- 
tain, that in some cases of abscess of the brain, we find in the 
seat of suppuration nothing else than a congeries of cellular tis- 
sue, which in all probability is the only source from whence the 
pus is derived, inasmuch as the nervous tissue has completely 
disappeared from the part. Certain white softenings of the 
brain have been regarded by some authors as the effect of a 
purulent infiltration of the nervous tissue. This opinion is, in 
my mind, a mere gratuitous hypothesis; there is no proof what- 
ever of the presence of pus in these cases of softening ; all that 
the most minute examination can detect, is a diminution in the 
consistence of the nervous tissue, which in those cases appears 
to manifest a disposition to return to its original state. 

There is not one of the parenchymatous tissues in which pus 
has not been found; in these, as in all other parts, it is some- 
times found in the state of infiltration, and sometimes in the 
state of abscess. Infiltration is most common in the lungs, and 
the form of abscess in the liver. 



LESIONS OP SECRETION. 303 

The tissues in which pus is found, whether in the state of in- 
filtration or of abscess, do not present any peculiar lesion which 
can be regarded as the cause of the purulent secretion. It is 
now no longer believed that pus can only be formed where 
there is ulceration. In a great majority of cases, the presence 
of pus is accompanied with anatomical signs of irritation. Thus 
we find, in the immediate vicinity of the suppuration, 1. various 
shades of hypersemia; 2. different varieties of softening; 3. 
solutions of continuity, which appear in some cases to have 
preceded, and in others to have followed the suppuration; 4. 
the disappearance of the proper tissue of the organ where the 
pus is collected, and its place occupied by cellular texture, in 
the areolae of which the pus is infiltrated. When the suppura- 
tion is limited, constituting what in medical language is termed 
an abscess, the pus is contained in a cavity, the parietes of 
which are sometimes formed by the naked tissue of the organ 
where the abscess is formed, sometimes again they are lined 
by an inorganic layer apparently composed of the more con- 
crete part of the pus, and, lastly, they are in some cases lined 
by an organized membranous layer, which in its appearance 
bears a more or less perfect resemblance to the natural mucous 
membranes. (See the article on mucous transformation.) 

There are, however, other cases in which no symptoms an- 
nounce during life the formation of pus in those parts where it 
is found after death; and in which anatomy can detect no trace 
of irritation having existed then, or at any antecedent period, 
in the seat or neighbourhood of the suppuration. Every thing 
appears in its natural state; neither the colour, consistence, nor 
thickness of the part, are in any respect altered ; molecules of 
pus are found lodged between the molecules of the solid, and 
this constitutes the only morbid alteration that can be appre- 
ciated. It frequently happens that this accumulation of pus un- 
accompanied by any appreciable disease of the surrounding 
solids, is not. confined to a single point, but exists at the same 
time in different parts of the system ; as, for instance, in several 
parts of the intermuscular cellular tissue, in the liver, spleen, 
lungs, and brain. Each of these organs may contain either a 
single collection of pus, or may be so studded with them, as to 



304 LESIONS OF SECRETION. 

render it almost impossible to count them. I have myself on 
one occasion reckoned more than thirty in one lung. When 
the vessels are examined in these cases, we sometimes find pus 
mixed with the blood contained in the heart, arteries and veins; 
it is likewise sometimes found in the lymphatics ; but in other 
cases not the slightest vestige of pus can be detected in any of 
these vessels. I may also remark with respect to these cases, 
that, in some instances, no appearance of suppuration is to be 
observed except in the vessels, and in the points where these 
purulent collections exist ; but that in other instances, and they 
arc by far the most general, these purulent collections thus dis- 
seminated through the system, make their appearance in those 
cases where some capital operation, such as an amputation, 
has been performed ; especially when the effect of the oper- 
ation is to remove a part from which a purulent discharge had 
been kept up for some time previously. Lastly, it is by no means 
uncommon to meet these numerous depositions of pus in women 
who, shortly after their confinement, are carried off by in- 
flammation of the uterus and peritoneum. In such cases the 
pus, instead of forming distinct collections, may infiltrate the 
surrounding tissues in such a way, as that no appearance of 
any fluid can be observed, and that the only perceptible alter- 
ation consists in the unusual colour which these tissues present 
in the infiltrated parts. In this way are formed these grey or 
yellow masses which are frequently found, after serious opera- 
tions, for example, in the different parenchymatous organs. At 
first they are hard, and bear a strong resemblance to portions 
of lung in a state of grey hepatization, or to that appearance 
which has been denominated tubercular infiltration; but, after 
remaining in this situation for a variable time, they gradually 
become soft and fluid, in consequence of the purulent matter, 
at first combined molecule to molecule with the organized tis- 
sue, subsequently separating and detaching itself, in order to 
form a distinct collection. 

I think no doubt can reasonably be entertained that these 
purulent depositions are the result of absorption, in those cases, 
at least, where they are found in persons who had had a sup- 
puration more or less extensive going forward in some part of 



LESIONS OF SECRETION. 305 

the system, at a short period before their death : the pus, when 
taken into the torrent of the circulation, is separated from the 
circulating fluid on the surface, or in the interior of the differ- 
ent organs; just as mercury, when injected into a vein, is 
found to deposit its globules in different parts of the body, but 
more especially in the lungs and liver. As to those compara- 
tively rare cases in which similar collections of pus have been 
observed without any evidence of an antecedent suppuration 
having existed, (as in the case I have already alluded to, where 
we found a collection of pus in the centre of a coagulum of 
blood, without being able to discover a particle of it in any 
other part of the system,) we cannot, in the present state of 
the science, form any rational conjecture as to their origin or 
cause. We must for the present be content to deduce from 
them the conclusion, that pus may be formed in a solid, or in 
a solidified fluid, such as coagulated blood, even in those cases 
where no trace of irritation, or congestion, or of alteration of 
texture, can be discovered either by the examination of symp- 
toms during life, or of the different organs on dissection. It is 
certain that there are some individuals in whom pus is much 
more readily formed than in others ; so that a purulent dia- 
thesis may be admitted with as much reason as a tubercular 
diathesis : in the latter, most pathologists are agreed in renoun- 
cing the supposition of an antecedent congestion or irritation 
being necessary to the developement of tubercles, when they 
are found in almost every part of the system. Why, then, 
may not the same be the case with respect to pus ? 

M. Marechal,* one of the most distinguished pupils of Pro- 
fessor Roux, has recorded, in his Inaugural Dissertation, seve- 
ral facts of this description, collected in the surgical wards of 
La Charite. I have already stated, that it was by no means 
uncommon to find collections of pus deposited in several of 
the internal organs, in those cases where amputation of the 
extremities had been performed : in addition to a numerous list 



*Recherches sur certaines Alterations qui se developpent au sein des principaux 
Visceres, a la suit des blessures ou des Operations, par M. Marechal, 4 to. 182S. 

Vol. I. 40 



306 LESIONS OF SECRETION. 

of cases of this discription, M. Marechal relates two instances 
of similar collections having been found after the removal of 
cancerous breasts. In one of these, besides the collections in 
the lungs, there were an innumerable quantity of small ones 
in the substance of the brain. Our author states that he has 
also frequently found them in the following cases. 1. After 
operations for the stone, where the operation was followed by 
suppurative inflammation of the cellular tissue of the pelvis. 
2. After excessive urinary abscesses, which had quickly proved 
fatal. 3. After the tapping of a hydrocele. 4. After the liga- 
ture of the femoral artery round which an abscess formed, 
accompanied with extensive phlebitis: in this case, and in the 
preceding, the collections of pus were exclusively confined to 
the lungs. 5. After four operations for fistula in ano; in three 
of these cases the lungs were the only organ in which pus was 
found ; in the fourth, it was found also in the liver. M. Hervez 
de Chegoin* has recorded a remarkable case he saw at La 
Charite, of an individual with an abscess in the pelvis, who 
died almost suddenly at the very time when he was supposed 
convalescent. On opening the body, pus was found in the 
ventricles and in the substance of the brain. 



SECOND SPECIES. 



TUBERCLE. 

This term was employed in medical language at a very 
early period, since it occurs in the works of Galen. For a 
length of time, it was applied to a variety of morbid altera- 
tions possessing no character in common except their form, 
which, as the etymology of the word indicates (it being a di- 
minutive of tuber) was that of a small tumour developed in the 



* A case reported to the dcademie Royale de Medecine (section de medecine) at 
the sitting of the 29th January, 1828. 



LESIONS OF SECRETION. 307 

interior, or on the surface of an organ. In this acceptation, 
the name of tubercle was given, as readily to an enlarged cuta- 
neous follicle, as to that accidental production in the lungs to 
which it is at present still applied. Its signification, however, 
became subsequently more restricted ; and, instead of being 
used as a synonyme for tumour, the term has for some time 
been employed exclusively to designate a morbid production 
distinguishable by certain physical characters ; a body, namely, 
of a yellowish white colour, in form most commonly round, 
extremely variable in size, at first hard but friable, afterwards 
softening and becoming transformed into a heterogeneous mat- 
ter, composed of whitish curdy masses suspended in a sero- 
purulent fluid. When once the tubercle has undergone this 
change, it acquires a tendency to quit the situation where it 
was originally formed, leaving behind it an ulcerous cavity, 
which sometimes extends more or less rapidly in every direc- 
tion, sometimes remains stationary for an indefinite period, 
and, lastly, sometimes becomes cicatrized. 

From this description it appears, that tubercle does not pre- 
sent the same uniform appearance in the different stages of its 
existence ; indeed, according to many authors, the transforma- 
tions it undergoes are still more numerous than those I have 
just described. Thus, according to Dr. Baron,* tubercle is at 
first a transparent vesicle, a hydatid. Professor Dupuy,f of 
the veterinary college at Alfort, has likewise adopted this 
opinion. I have endeavoured to ascertain its truth by exam- 
ining both the human subject and different animals, particularly 
the horse ; and the following are the results of my observa- 
tions. It is quite certain that, in some few cases, small, round, 
transparent vesicles, filled with a serous fluid, are found along 
with undoubtedly genuine tubercles of various sizes. In the 
lungs of phthisical horses, for instance, I have more than once 
found cysts of this description ; but I have never been able to 



* Traite des Maladies Tuberculeuses, by Baron, translated from the English 
by Madame Boivin, 1 vol. 8vo. 

j Traite de VAffeciion luberculeuse, fyc. by Dupuy, in Svo. 1817. 



308 LESIONS OF SECRETION. 

find them in the human subject, except in one solitary case, in 
which the lungs contained also numerous tubercles, some hard, 
others soft, and others, again, transformed into irregular cavi- 
ties. In the horse, I have sometimes seen the fluid contained 
in these vesicles lose its transparency, and become turbid ; and 
the entire vesicle thus assume the aspect of the opaque white 
tubercles around it. From this, which is all I have been able 
to observe, I think we may draw the following conclusions. 

1. The transparent vesicles, which, in some rare cases, are 
found among tubercles, are only accidental productions with 
which these latter are complicated. 

2. They cannot be considered as the origin of the tubercles,, 
or as their primary form ; for, in that case, they would be met 
with much more frequently. It is surely impossble that, where 
we have constant opportunities of examining pulmonary tuber- 
cles in man, in all their shapes and stages, they should have 
been but once found in that particular one. 

3. It may so happen that these vesicles secrete, in place of 
the serosity which they usually contain, a substance whose 
physical characters approach more or less to those of tubercle ; 
but is this a sufficient reason for establishing that the forma- 
tion of the latter is always preceded by the developement of a 
serous sac, to serve as its secreting organ ? As well might we 
assert that a mucous follicle is the constant secreting organ of 
tubercle, because matter of a tuberculous appearance has been 
sometimes found in such a follicle ; or again, that tubercles are 
invariably seated in the lymphatics, because a matter more or 
le'ss analogous to it has been occasionally found in these vessels. 

The co-existence of serous cysts and tubercles which is so 
exceedingly rare in man, and very rare even in the horse, be- 
comes much less so in other species. In the hog, for instance, 
these productions exist almost always together ; and in the dis- 
ease called measles, to which that animal is subject, the cysts 
are even more numerous than the tubercles. This co-existence 
has, probably, misled those who viewed such cysts as the first 
stage of tubercle. We must also be on our guard not to take 
for a transformation of cyst into tubercle, certain cases in 
which, as I once saw in a rabbit's liver (Clinique Medicate* 



LESIONS OF SECRETION. 309 

vol. iii.) tubercular matter is deposited around hydatids, just as 
a layer of pus is often found about a foreign body. 

In my opinion, therefore, the original form of tubercle is not 
a serous vesicle ; neither is it a greyish, semi-transparent gran- 
ule, as Laennec maintained. According to his idea, the white 
opaque corpuscule constituting tubercle, is not what is observed 
in the first instance ; but is preceded by a greyish, semi-trans- 
parent granule, in whose centre is subsequently developed a 
white point, which by degrees extends to its surface, and in- 
volves its whole substance ; so that this granule is really the 
first stage of tubercle. To this opinion may be offered the 
following objections. 

If tubercle commenced necessarily by being a greyish semi- 
transparent granule, this latter should have been observed in 
every part of the system where tubercles have been found. 
Now, I would ask, have such granules been observed in the 
lymphatic ganglions, where tubercle can be followed in all the 
phases of its developement? Have they been found in the 
brain, in the liver, in the spleen, in the submucous, subserous, 
or intermuscular cellular tissue? M. Chomel has, certainly, 
related a very singular case of an individual whose brain con- 
tained thirty or forty small globular bodies, resembling in size, 
colour and consistence, the human crystalline lens; similar pro- 
ductions were also found in the lungs, on the surface and in 
the parenchyma of the liver, spleen, and kidneys, and in the 
phrenic portion of the peritoneum.* But, to judge from M. 
Chomel's description, these bodies thus formed simultaneously 
in almost all the organs, did not at all resemble the granules 
usually found in the lungs, and regarded by Laennec as the 
first stage of tubercle. Neither is there the least resemblance 
between the common pulmonary granules and those small, 
greyish, irregularly rounded bodies, which are at times found 
studding the free surface of serous membranes, and which seem 
to me to be nothing but rudiments of false membrane. As to 
those greyish granules which are observed sometimes on the 



*Dkti<mnairc de Medicine, by Adelon, Andral, Beclard, &c. art. Gramdaturi, 



310 LESIONS OP SECRETION. 

surface of mucous membranes, I have never considered them 
to be any thing but follicles in a state of hypertrophy. Here, 
then, we have several morbid alterations resembling each other 
in form, but essentially different both in their origin and nature. 
In all these bodies, called by the generic name of granulation, 
tuberculous matter may undoubtedly be formed, just as pus 
may; but I deny that they are invariably the primary origin of 
tubercle. Thus we very often find in the lungs whitish points, 
which are genuine tubercles, appearing in the very midst of 
granulations; but there is nothing extraordinary in that, inas- 
much as these granulations are, in most instances, merely the 
effects of partial pneumonias,* and tubercle has an especial ten- 
dency to develope itself wherever there exists a chronic process 
of irritation. 

Another opinion has recently been advanced by M. Cruveil- 
hier, namely, that before the occurrence of tubercle as a hard 
body, and at an earlier period of existence, it may be detected 
in a fluid puriform state. While conducting some experiments 
on the artificial production of tubercles in animals, and exam- 
ining their bodies as soon as possible after the developement of 
those tubercles had commenced, he observed among some hard 
white bodies, others which differed from them only in their in- 
ferior degree of consistence, being in a fluid state. In human 
lungs, filled with tubercles, I have occasionally found, scattered 
through their substance, white points composed of a fluid sub- 
stance like a drop of pus. In the lungs of horses, too, M. M. 
Trosseau and Leblanc have seen, among well formed tuber- 
cles clusters of points, in some of which was a purulent infil- 
tration, in others were small abscesses. These different facts 
seem to afford some confirmation to the opinion of M. Cruveil- 
hier, but we must always take care to distinguish between what 
is constant, and what is only accidental. Now, I think it proba- 
ble enough that tubercle is in the fluid state at the moment of 
its deposition; but the fact does not appear to have been as yet 
sufficiently demonstrated; and it is quite certain, that, be the 



* Vid. Cliniquc Medicate, Maladies de rvitrinc, and vol. ii. of the present work. 



LESIONS OF SECRETION. 311 

tubercle ever so small, it is most frequently found in the solid 
state.* 

We shall, therefore, take it for granted, that tubercle is in its 
first stage, when it appears under the form of an opaque, friable, 
rounded body, of a yellowish white colour, and without trace 
of organization or texture. After having continued in this state 
for a period of which the duration may vary from only a few 
weeks to many years, it is susceptible of two species of trans- 
formations, namely, the purulent, and the cretaceous. 

The only appreciable modification tubercle undergoes pre- 
viously to the commencement of either of these transforma- 
tions is an increase of bulk ; and the first question for us to 
examine is, how this takes place ; how a body whose size does 
not at first exceed that of a small pin's head, can acquire in 
time the bulk of an ordinary orange. 

To account for this enlargement, an hypothesis has long 
been current, by which tubercle is supposed to have the power 
of growing by intus-susception, like organized living beings. 
Now, it is not because I consider tubercle as a product of secre- 
tion, that I oppose this opinion ; for it might, notwithstanding, 
when once secreted from the blood, become susceptible of 
organization and life, like the fibrine which is effused on the 
surface of a serous membrane when irritated. In the fibrine, 
however, it is easy to demonstrate the existence of vital 
actions ; but none such have ever been detected in the matter 
constituting tubercle. If, then, this matter is not endowed 
with life, it cannot grow, like living bodies, by intus-suscep- 
tion ; it can only increase in bulk, as inorganic bodies do, by 
juxtaposition. Wherever the secretion of tubercle has once 
commenced, that process continues : each particle of living 
matter, instead of the perspiratory fluid which it usually sepa- 
rates from the blood, takes from it a particle of tuberculous 
matter, which, added to those already secreted, tends to in- 
crease their mass. All tuberculous matter, then, is in this 



* We must not imagine that every product of secretion appears at first in the 
fluid state ; for there are some, the cuticle for instance, which never appear but 
in the solid state. 



312 LESIONS OF SECRETION. 

manner infiltrated among the tissues of the part. In some in- 
stances, traces of those tissues can still be recognized in the 
midst of the tubercular mass, and to them belong the vessels 
sometimes found traversing it. In others, the tissues being 
confined, and constantly more and more compressed, cease to 
be distinguishable, and nothing is to be found but a homo- 
genous mass of tuberculous matter. In some cases this mass 
has a tendency to isolate itself by degrees from the surround- 
ing living parts, and a cyst becomes organized around it, just 
as it would be around a collection of pus, or any foreign body. 
Here, then, we see tubercle acting like pus : it first infiltrates 
the tissues in which it is formed, and then proceeds to isolate 
itself from them. 

The purulent transformation of tubercle is what has been 
termed its period of softening. The cause of the change of 
consistence which the tubercle then undergoes, no more ex- 
ists in itself, than the cause of its increase of bulk.* Each 
particle of tuberculous matter, acting like a foreign body on 
the tissues with which it is in contact, produces in each cor- 
responding point of these tissues a secretion of pus which me- 
chanically effects the division of the tubercle into clots, and 
and which occurs here in the same manner as it does in all 
cases where a foreign body has been lodged for any time in 
some part of the living system. In the place where such a 
body is deposited, there is first formed a process of irritation, 
then a secretion of pus, and eventually, in most cases, a solution 
of continuity, by which a way is opened for its escape. In the 
case of tubercle the process is similar. Its softening, then, is 
merely the result of the disuniting and separating of its particles 
by pus ; and the end of this process is, as in the case of the 
foreign body, the expulsion of the tubercle. But, after this 
has been accomplished, the process of suppuration may con- 
tinue, and, moreover, the same cause which had produced the 



* M. Lombard, of Geneva, appears to me to be the first who has given a good 
theory of the softening of tubercle, in an excellent work on that subject, to which 
I am indebted for many of the facts brought forward ID this article. 



I/ESIONS OF SECRETION. 313 

tubercle before, may produce it again ; the same process which 
eliminated it may contribute to the renewal of its formation : 
so that, far different in this respect from a foreign body intro- 
duced from without, the tubercle may be indefinitely re-created 
simultaneously with the pus destined to produce its elimina- 
tion. It has been asserted, that the softening of tubercles 
commences always at their centre ; it certainly does in a great 
many cases, but they may also begin to soften in other parts, 
and especially towards their surface. 

We sometimes find that tubercle, in place of softening, ac- 
quires an unusual hardness, and becomes transformed into a 
gritty mass, in which chemical analysis shows a notable quan- 
tity of phospate and carbonate of lime. These salts are also 
found, but in much less quantity, in ordinary tubercles; so that 
their cretaceous transformation is merely a withdrawing, a re- 
absorption of the animal matter which is their chief constitu- 
ent, and an augmentation of secretion of the calcareous matter. 
Thus, in some pulmonary tubercles in the unsoftened state, 
which were lately analyzed in the laboratory of M. Thenard, 
at the College de France, there were found in 100 parts, 

Animal matter - - - - 9S.15 

Muriate of soda \ 

Phosphate of lime ( . . 1.85 

Carbonate of lime ) 

Oxide of iron - - - - a trace 

Other tubercles which had undergone the cretaceous trans- 
formation, presented inverse proportions of those substances ; 
that is, in 100 parts, 

Animal matter 3 

Saline matter ----- 96 

The cretaceous transformation appears to occur more par- 
ticularly in those cases where the tubercles have long ceased 
to exert any hurtful influence on the constitution ; and is in 
this respect the reverse of the purulent transformation. 
Vol. I. 41 



314 LESIONS OF SECRETION. 

We sometimes meet with it in situations in which, long 
long before death, more or less decisive symptoms had an- 
nounced the existence of tubercles, which afterwards ceased to 
afford any indication of their presence. Often, too, there is 
found about the cretaceous tubercle a tissue that appears 
shrunk, and occupies less space than in the natural state ; and 
we have reason to believe, in some cases, that this tissue has 
actually been in part destroyed, and absorbed along with a 
tubercular mass of greater or less extent, whose remains ap- 
pear as a chalky concretion. This conjecture receives addi- 
tional support from the fact, that tubercles in the softened state 
are sometimes found containing, among the curdy masses float- 
ing in the purulent fluid, some hard, gritty particles, formed of 
phosphate of lime. If we submit such tubercles to the action 
of an elevated temperature, or expose them for some time to 
the air, the liquid part evaporates, and we then, in place of a 
semifluid heterogeneous mass, find only a homogeneous con- 
cretion. 

As tubercle is produced by the perspiratory secretion, of 
which it appears to be a morbid alteration, it may be developed 
in every part of the body : the situation, however, in which it 
is most usually secreted, seems to me to be the cellular tissue, 
whether free or combined. The submucous, subserous, and 
intermuscular tubercles, are evidently developed in this tissue ; 
it would be difficult to prove that the same holds good of 
tubercles of the spleen ; and we can admit it only by analogy 
in those of the brain, liver, kidneys, testicles, and lymphatic 
ganglions. As to the lungs, by examining dried sections of a 
tuberculous lung with a magnifier, or even with the naked eye, 
we may detect tubercles in the substance of the cellulo-vas- 
cular tissue which forms the parietes of the air vesicles and 
the infinitely small bronchial tubes opening into them. An 
apparently tuberculous matter has been found in the interior 
of cavities lined with mucous membranes, without the pres- 
ence of ulceration : this fact, of which there are as yet very 
few instances, shews the possibility of tubercles being secreted 
in other tissues than the cellular. It is not very uncommon 
to find the mucous follicles filled with a substance which has 



LESIONS OP SECRETION. 315 

exactly the aspect of tuberculous matter ; and I have more 
than once found the same substance in the lymphatic vessels, 
which then appeared under the form of whitish knotted cords : 
some of them proceeded from organs containing tubercles, 
others from parts which were free from that affection, but were 
in a state of acute or chronic irritation, or else presented no 
appearance whatever of disease. For instance, I have often 
seen lymphatics full of a whitish matter like that of tubercle, 
proceeding from intestinal ulcerations, and losing themselves 
in the mesentery, while no where else in the intestine were 
traces of this matter to be found. A woman died at La 
Charile of a cancer of the uterus, in August, 1824. On open- 
ing the body, it was found that the mesenteric ganglions and 
those of the hollow of the pelvis formed hard white masses of 
great size in front of the vertebral column. The inguinal and 
bronchial ganglions presented the same alteration ; and from 
several of the former proceeded vessels distended with a lim- 
pid colourless serosity, which presented, at intervals, white 
points capable of being displaced by a slight pressure. It ap- 
peared, then, that the matter which formed these white points 
was contained in the calibre, not in the parietes of the vessels ; 
and in fact, on making a slight incision, it escaped freely by the 
sole action of their elasticity. It was of a dull white colour, 
and of a moderate consistence, readily breaking down under 
the finger ; it was, in short, genuine tuberculous matter. Some 
of the lymphatics thus distended by it at intervals, could be 
easily followed under the crural arch, and into the pelvis, to 
the middle of the mass of diseased ganglions in front of the 
spine. The thoracic duct disengaged itself from this mass, op- 
posite the last dorsal vertebra ; and was, in three or four 
places, greatly distended, and in a manner obstructed, by the 
same whitish substance already described, which here formed 
masses, one of which was as large as a nut, and which were 
also evidently contained in the calibre of the tube, without 
having any connexion with its tissue. The external surface of 
both lungs was traversed by a great number of white striae, 
exactly similar in their disposition to lymphatic vessels injected 
with mercury. These striae were really lymphatics distended 



316 LESIONS OF SECRETION. 

with a matter analogous to that contained in the others and in 
the duct. It was easy to follow some of them into the bron- 
chial ganglions, which were themselves transformed into hard 
white masses. The interior of the lungs, especially the left, 
likewise contained several of these vessels, appearing like 
white thread, and distended at intervals. In some spots, they 
were isolated ; in others, more or less crowded, forming a kind 
of plexus. Nothing resembling tubercle was to be found in 
any part of the lungs. Neither the parietes of the different 
vessels in which the whitish substance occurred, nor those of 
the thoracic duct, presented any appreciable alteration. I 
shall not attempt to decide, whether this tuberculous looking 
matter was formed in the vessels in which it was found, or in- 
troduced by absorption. I shall only remark, that, if the blood 
has the power of coagulating in its vessels, and of assuming 
therein the most different appearances, even to the extent of 
becoming transformed into the substance called encephaloid, or 
into pus, it is not surprising the serous fluid of the lymphatics 
should also possess the power of spontaneously becoming solid 
within them, and, having once passed into this state, of under- 
going those same alterations, of which observation has ascer- 
tained the possibility in the case of the blood. 

Whatever be the tissue in which the tubercular matter orig- 
inates, it does not appear with equal frequency in every 
organ. In the adult, the parts that most frequently become 
tubercular, are, first the lungs, and next, the small intestine. 
In three hundred and fifty subjects, M. Louis found (not count- 
ing the lungs) tubercles 

In a third of the subjects . . in the small intestine. 

In a ninth in the great intestine. 

In a fourth in the mesenteric glands. 

In a tenth . in the cervical glands. 

In a twelfth in the lumbar glands. 

In a thirteenth in the prostate. 

In a fourteenth in the spleen. 

In a twentieth in the ovaries. 

In a fortieth in the kidneys. 



LESIONS OF SECRETION. 317 

In one in the uterus. 

Ditto . . in the cerebrum. 

Ditto in the cerebellum. 

Ditto in the ureter. 

If these observations had been made in surgical practice, 
we should have had a different result. There would have 
been mentioned, for instance, tubercles of the testicle, which, 
though common enough, are not taken into account in the table 
of M. Louis.* Tubercles of the bones would also have been 
introduced. 

In the three hundred and fifty subjects he examined, M. 
Louis found but one in which tubercles occurred in different 
other organs without their being any in the lungs. 

In one hundred adult subjects, Dr. Lombard found, not 
counting the lungs, tubercles 

In the intestines, in 26 cases. 

In the mesenteric ganglions 19 

In the bronchial ganglions 9 

In the cervical ganglions 7 

In the spleen , . . . 6 

In the lumbar ganglions 4 

In the subperitoneal cellular tissue 4 

In the axillary ganglions 3 

In the ganglions of the anterior mediastinum . . 3 

In the subarachnoid cellular tissue 2 

In the spinal cord 2 

In the false membranes of the pleura .... 2 

In those of the peritoneum .2 

In the intercostal muscles 2 

Ovaries 2 

Parietes of the gall bladder 1 

Liver 1 

Cavity of the pleura 1 



* Recherches sur la Phthisie Pulmomire, 



318 LESIONS OF SECRETION. 

Posterior mediastum 

Vertebrae 

Ribs - . . 

Omentum 

Uterus 

Prostate 

Submucous tissue of the bladder . . 
Cerebrum and cerebellum .... 
Medulla and oblongata ..... 

Kidneys 

Vesiculse seminales 



From my own observations, I have arrived at the conclu- 
sion, that the relative frequency of tubercles in the different 
organs, observes nearly the same order as that indicated in the 
preceding tables ; except that I have in more cases than M. 
Louis, found tubercles in other organs without there being any 
in the lungs, and I have discovered them in the false mem- 
branes of the pleura and peritoneum, in a greater proportion 
of cases than M. Lombard. Besides the testicle, in which the 
tuberculous matter, when it occurs, constitutes a variety of 
sarcocele, both authors have also omitted to mention the in- 
tervertebral cartilages, in which I once found a mass of tu- 
bercles. 

In children, tubercles, with respect to their situation, differ 
from those of the adult in the following circumstances. 

1. Tubercles occur in other organs without there being any 
in the lungs, more frequently in children than in adults. 

2. They have also a tendency to effect a greater number of 
organs at once. 

3. The organs which are the most frequently affected in adults, 
are not those which are so in children. This may be seen on 
comparing the following table* with the two preceding. 

In a hundred young subjects, M. Lombard found tubercles 



* Lombard, op. cit. 



LESIONS OF SECRETION. 319 

In the lungs, in 73 cases, in 30 of which but one lung was af- 
fected, viz. the left in 13, and the right in 17 cases. 

In the bronchial ganglions, in 87 cases. 

In the mesenteric ganglions 31 

In the spleen 25 

In the kidneys 11 

In the intestines . 9 

In the nervous centres 9 

In the cervical ganglions 7 

In the membranes of the brain 6 

In the pancreas 5 

In the gastro-hepatic ganglions 5 

In the subperitoneal cellular tissue 5 

In the spleen 4 

In the inguinal ganglions 3 

In the cellular tissue under the pleura .... 2 

In the lumbar ganglions 

In the submucous tissue of the bladder .... 

In the omentum 

In the parietes of the gall bladder 

In the false membranes of the pleura .... 

It is remarkable that in these hundred young subjects, tuber- 
cle was not found in the liver in one single instance. On com- 
paring this table with the preceding, we see, that in two hund- 
red subjects young and adult, tubercles were found but once 
in that organ, while they were found thirty-one times in the 
spleen, but not with equal frequency in both classes ; as they 
occurred in the one-fifth of the cases in the young, and only in 
the one-sixteenth in the adult. In the latter, the intestines are 
more frequently tubercular than the mesenteric ganglions; the 
reverse is the case in children. It would result too, from the 
preceding tables, that intestinal tubercles occur more rarely in 
children than in adults. I confess that my own experience 
would have led me to the opposite result ; so that I think this 
fact requires to be verified on a greater scale. We find also, 
from these tables, that the proportion of tubercles in the bron- 
chial ganglions is much greater in children than in adults ; a 



320 LESIONS OF SECRETION. 

fact which I have long considered as certain ; indeed it appears 
from the same source, that they are more frequently found in 
those ganglions, in children, than in the lungs. I have also ob- 
served in the adult, but far more rarely, tubercles in the bron- 
chial ganglions without there being any in the lungs. (Clinique 
Medicale, diseases of the chest.) On the contrary, it is very 
common to observe, after puberty, tubercles in the lungs with- 
out there being any in the ganglions; this is even the most gen- 
eral case. As to the cervical ganglions, we see how small is 
the number of cases in both classes, where they have been 
found tubercular, in comparison with the cases where tubercles 
were found in the lungs. 

Lastly, these tables also confirm a fact generally known, the 
greater frequency of tubercles in the nervous centres in chil- 
dren than in adults. 

The examination of the relative frequency of tubercles at 
the different ages, without considering in what organs they 
occur, will lead us to the following results. 

1. Tubercles are but very rarely developed in the foetus. 

2. During the first month after birth, they are likewise very 
rare. 

3. From after that period till towards the age of four years, 
they occur rather more frequently, but still few in number. 

According to the researches made by M. Lombard at the 
Hopital des Enfans Malades at Paris, tubercles are found in 
only one-eighth of the children who die between the ages of 
one and two; in two-sevenths of those between two and three; 
and in four-sevenths of those who die between three and four 
years of age. 

4. Between the ages of four and five, in consequence as it 
were of a sudden developement, tubercles appear in much 
greater quantities, and in a greater number of organs at once. 
It results from the researches of M. Lombard, already cited, 
that, at this age, three-fourths of the children who die are vic- 
tims of some tubercular affection ; or, at all events, on being 
opened present a greater or less number of tubercles in differ- 
ent parts. At this age, then, every irritation or congestion is 
far more to be dreaded than in the preceding years, inasmuch as 



LESIONS OF SECRETION. 321 

it may be more easily followed by the production of tubercles. 
It often happens that children, while still very young, towards 
the period of weaning for instance, are attacked by an intestinal 
or pulmonary irritation, which disappears after having lasted 
for an uncertain period. They then recover their health, but 
many of them continue habitually pallid, their muscular system 
remains imperfectly developed, and their limbs are slight; they 
are in fact what is called delicate : some are affected occasion- 
ally with either cough or diarrhoea; others do not present even 
these symptoms. At last, towards the age of four or five, the 
cough returns, but in a much severer and more obstinate form; 
the digestive functions become deranged, emaciation succeeds, 
a fatal termination ensues, and, on opening the body, tubercles 
are found in every part of it. 

5. In the succeeding ages, up to the period of puberty, the 
tubercles are more numerous than they were before the age of 
four years, but are much less so than between the fourth and 
fifth year. 

6. From the period of birth up to the fifteenth year, from 
one to two is, according to M. Lombard, the age at which 
fewest tubercles are found ; on the contrary, between four and 
five, is that at which they are most common. 

7. After puberty, tubercles again become more frequent, 
and that, no longer in all the organs indifferently, but only in 
the lungs, in the intestines, and in some parts of the lymphatic 
system. Between eighteen and forty they are very common, 
but are, however, a less cause of mortality than in childhood 
between four and five. In this interval, some ages have been 
marked as appearing to favour the developement of tubercles, 
but we have not yet attained to any great certainty on this 
head. It appears to me, however, to result, from the re- 
searches of this kind hitherto published, as well as from those 
which I have been able to make myself, that males, after 
puberty, are particularly subject to tubercles between the ages 
of twenty-one and twenty-eight; while females seem to be 
more exposed to them before twenty. As, however, after the 
period of puberty, tuberculous affection becomes almost sy- 
nonymous with pulmonary consumption, the second volume of 

Vol. I. 42 



322 LESIONS OF SECRETION. 

this work, as including the diseases of the respiratory appa- 
ratus, will be the proper place to return to this question, now 
but slightly touched upon. For this reason, I think it best to 
defer the detailed account of what has been done with a view 
of determining the relative frequency of phthisis pulmonalis at 
different ages. 

The developement of tubercles is not peculiar to man ; they 
have been likewise ascertained to exist in many beasts. In the 
first place they often occur in the apes that die in our menage- 
ries ; and that in several organs at once. Thus I had an op- 
portunity, lately, of examining the body of a male of the spe- 
cies Simla JEiltiops, that had died at the Jardin clu Roi, and 
found in it tubercles existing simultaneously in the lungs, (which 
were quite stuffed with them,) in the liver, spleen, axillary and 
mesenteric ganglions, and under the mucous membrane of the 
intestines. A tuberculous mass, developed in the neighbour- 
hood of the anterior mediastinum, had perforated the pericar- 
dium, and appeared to be the cause of a pericarditis which had 
existed in the animal, and had probably hastened its death. 
Cases of pleurisy and peritonitis, produced by the irruption of 
tuberculous matter into the peritoneal or pleural cavity, have 
been more than once observed in man ; but I know not whether 
a pericarditis produced by a similar cause, has as yet been ob- 
served in the human subject. M. Hippolite Royer Collard in- 
formed me, that last year, at the menegarie, he opened the 
body of a lion, in which the lungs contained a number of 
tubercles with hepatized pulmonary tissue between them. 

I have likewise ascertained the frequent existence of tuber- 
cles in the following animals. 

1. In horses. I have examined the bodies of these animals 
at the slaughter houses at Montfaucon, where this affection was 
so common in the spring and summer of the year 1824, that of 
six horses, the average number slaughtered at each of my visits, 
I almost constantly found tubercles in one, and often in three. 
In the horse, the parts where I have most frequently ob- 
served tubercles, are, the pituitary membrane, or rather the 
cellulo-fibrous tissue which separates it from the osseous and 
cartilaginous parietes of the nasal fossae, and next to it, the 



LESIONS OF SECRETION. 323 

lungs. Of the lymphatic ganglions, the sublingual and bron- 
chial appeared to me most frequently to manifest the process 
of tubercular secretion. It results from an estimate made by 
Professor Dupuy,* that almost every time tubercles are ob- 
served in the nasal fossae, they are also to be found in the sub- 
lingual ganglions. In fact, of sixty-six cases of tubercles of 
the pituitary membrane, he found sixty with tubercles in the 
sublingual ganglions. From the researches of this author, the 
developement of tubercles in the bronchial ganglions does not 
appear to succeed with equal constancy their developement in 
the pulmonary parenchyma. Thus, of forty-two horses with 
tubercles in the lungs, he found but twenty-seven that had them 
also in these ganglions. Among seventy-two glandered horses, 
he observed thirteen cases of tubercles in the inguinual gangli- 
ons, and but six of that affection in the testicle. I have never 
been able to meet with tubercles in. the alimentary canal, or 
mesenteric ganglions, in this animal ; for we must not apply 
that term to tumours sometimes developed in the internal sur- 
face of the intestimes, which are nothing but follicles in a state 
of hypertrophy. This negative result proves at least the rare 
occurrence of intestinal and mesenteric tubercles in the horse ; 
a fact confirmed by the observations of Dupuy : in seventy- 
two glandered horses, he found tubercles of the intestines in 
two only, and of the mesenteric glanglions in four. The liver 
also, and spleen, sometimes contain tubercles; they appear to 
me more frequent in the latter than in the former : I have 
never been able to discover them in the nervous centres, 
neither does M. Dupuy make mention of such an occurrence. 
2. In the hog. In the body of one of these animals, which 
I examined along with M. Dupuy, I found tubercles at the 
same time in the lungs, in the heart, and in several groupes of 
muscles. In the heart and muscles they were mixed with 
transparent vesicles surmounted by a head-shaped prolonga- 



* De 1' Affection Tuberculeuse, vulgairement appellee morve, &c. by M. 
Dupuy, 8 vo. 1827. 



324 LESIONS OF SECRETION. 

tion, which appeared to be of that species of hydatid termed 
cysticercus. 

3. In the ox. In several dried specimens of cows' lungs, pre- 
sented by M. Dupuy to the Academie Roycde de Medecine, 
were numerous tubercles, which were remarkable for the cir- 
cumstance of their being much harder than usual, the calcare- 
ous salts appearing to predominate in their composition: it 
might, however, have been an effect of the drying. M. Larry 
lately sent me a rib of beef, in which was a round cavity con- 
taining a tubercular mass of the size of a large cherry. 

4. In the rodentia. It is not very uncommon to find tuber- 
cles in rabbits. In these animals, the liver is the organ in 
which I have most frequently observed them. Dr. Lombard 
told me he has found some in their intestines and mesenteric 
glands. M. Dupuy has seen tubercles in the liver and mesen- 
tery of a hare. 

Lastly, several authors inform us they have pretty frequently 
met with tubercles in the sheep. We are assured also, that 
amongst birds, the parrots in menageries almost always fall 
victims to a tuberculous affection. There is in the museum at 
Alfort the liver of a turkey which is full of tubercles. 

From the preceding facts it follows, that several animals 
have, in common with man, this melancholy tendency to tu- 
berculous affections. They shew us, that, amongst the mam- 
malia, animals using the most different kinds of food are 
equally subject to it; the carnivorous as well as the herbivo- 
rous. Amongst the carnivorous, however, there is one species, 
in which, though we frequently examine their bodies, genuine 
tubercles have never, to my knowledge, been discovered: I 
mean the canine species. Is this because the dog lives in free- 
dom in a climate that agrees with him, and where he can enjoy 
exercise proportioned to his strength? And is it because the 
lion happens to be in opposite circumstances that he dies af- 
fected with tubercle? Observe, that most of the animals in 
which we have just now proved the existence of this affection, 
are either transported from a hot to a cold climate, where they 
are deprived of liberty and exercise (as in the case with monk- 
eys and parrots), or confined in damp places, without sun, and 



LESIONS ON SECRETION. 325 

almost without air, (cows, pigs, house rabbits), or exposed 
either to continual alternations of cold and heat, or to con- 
strained and violent exercise, as the horse. 

The predisposing causes of tubercle are still far from being 
well known. Observation has proved that it has an especial 
tendency to grow in those individuals whose skin is very fair, 
and as it were, blanched, and without any trace of colouring 
matter in its capillaries, and in whom the prominences of the 
cheek exhibit a red tint, as if it were laid on with a brush, 
which forms a remarkable contrast with the dead white of the 
rest of the cheek. The colouring matter thus deficient in their 
skin is likewise so in their eyes, which retain the blue tint of in- 
fancy, and in their hair, which is light-coloured, and also small 
in quantity. Their muscles are soft and slender, and shew lit- 
tle contractile power; their blood is serous, and deficient in 
fibrine and colouring matter; and among their secretions the 
mucous predominate. In these individuals, lastly, sanguineous 
congestions are formed with remarkable facility in different 
parts of the skin and mucous membranes; and when once 
formed, never terminate, but continue in the chronic state, and 
are frequently succeeded by ulcerations and various disorgani- 
zations, which do not heal without the greatest difficulty, and 
that, often by the employment of measures the reverse of those 
termed antiphlogistic. It seems that such persons preserve in 
adult age several of the characters belonging to the age of 
childhood, considered in its healthy or morbid state; their or- 
ganization is in a manner arrested in its developement. Such 
a constitution as this may have been formed without any ex- 
ternal cause appearing to contribute to it. In other cases, it 
appears to have been acquired. The living in an impure or 
insufficiently ventilated atmosphere, the crowding together of 
a great number of persons, want of due exposure to the sun, 
habitual humidity of the atmosphere, the use of food which 
does not sufficiently repair the forces of the system, various 
excesses which exhaust these forces, and waste the nervous 
influence to the detriment of the nutritive powers; such are 
the causes, which, while they produce in the blood an impov- 
erishment indicated externally by the state of the skin and 



326 LESIONS OP SECRETION. 

muscles, and impress on every hyperemia a chronic or languid 
character, tend also to produce in every organ the secretion of 
tubercle. 

Thus, then, there are certain habits of body, certain consti- 
tutions, innate or acquired, that predispose to the developement 
of tubercle ; that is to say, it most frequently appears in those 
constitutions ; and it is a remarkable fact that it is in such cases 
especially we observe this morbid production developing itself 
in several organs at once, both in old and young. 

I do not mean, however, to assert that tubercles are found 
only in individuals like those just described; on the contrary, 
they occur also in others of a totally different constitution. It 
is not uncommon, for instance, to observe amongst the victims 
to consumption, some with a brown skin, very black hair, and 
strongly developed muscular system. Still, I think, I am borne 
out by facts in the two following positions : 1st, that the tuber- 
cular diathesis is in direct proportion to the developement of 
the constitution above described ; and 2nd, that in proportion 
as this constitution becomes less strongly marked, the tubercles 
also become less frequent, and, especially, occur in fewer or- 
gans at once. 

Thus, with respect to their predisposing causes, tubercles 
should, I think, be divided into constitutional and accidental. 
The first are distinguished by the two following characters : 
1st, their simultaneous existence in several organs ; and, 2nd, 
the very frequent absence of any appreciable symptoms of 
antecedent excitement or congestion in the part where they 
originated. To explain the presence of tubercles in several 
organs at once, it has been said that they were at first formed 
in some one of them, the lungs for instance, and were after- 
wards absorbed, introduced into the circulation, and deposited 
with the blood in the parenchyma of the other organs. Ac- 
cording to this opinion, the case would be with the tuberculous 
matter as with pus, which, as we have already seen, is capable 
of being thus absorbed, and deposited afterwards on the sur- 
face, or in the substance of the different tissues. It is possi- 
ble that the tuberculous matter also may possess this property ; 
but as yet there is no fact to prove it, and without having re- 



LESIONS OP SECRETION. 327 

course to such an hypothesis, its simultaneous existence in 
several organs can be very naturally accounted for by the sin- 
gle fact of an identity of modification in the whole of the per- 
spiratory secretion. 

But, in order that this modification may take place, is it ne- 
cessary that there should previously exist an exaltation of the 
vital powers of the part, augmentation of its organic action, 
stimulation, irritation, and, consequently, active hyperemia? 
This question is answered by experience, that in many cases 
there have been symptoms indicative of sanguinous congestion 
in those parts in which the tuberculous secretion was after- 
wards established ; but that in other cases there has been no 
proof that this sanguineous congestion, produced by irritation, 
had ever existed ; so that it can be admitted only by analogy. 
We then have to go back to reasoning, and, according to the 
meaning which is given to the word irritation, according as 
we attribute it to such or such a series of functional de- 
rangements, it will become free to every one to admit or deny 
the presence of irritation in those cases in which, after death, 
tubercles are found in most of the organs at once, without 
there having been any sign of its existence during life. All 
that can be established in this respect, are the three following 
propositions. 

1. In many cases, neither the study of the symptoms, nor 
the examination of the morbid changes in the dead body, dis- 
covers the past or present existence of a process of irritation 
in the part where the tuberculous matter is found. This holds 
good not only of those organs whose ' sensibility is feeble, and 
whose sympathies are of little activity, such as the lymphatic 
ganglions, liver, and spleen, but also of the brain. 

2. In the formation of tubercles, as well as in that of every 
other morbid production, theory shews that irritation is an en- 
ergetic and very frequent, but not a necessary cause. 

3. Irritation, without the concurrence of other causes, can 
no more account for the formation of tubercles, than for the 
particular nature of each of the innumerable alterations of nu- 
trition and secretion it so often precedes, and which are devel- 
oped not by it but through it. 



328 LESIONS OF SECRETION. 

Thus, the mere presence of irritation, be its intensity and 
duration what they may, does not necessarily determine the 
formation of tubercles ; on the contrary, they may occur with- 
out any appreciable irritation. 

To sum up all, it appears to me that, in the present state of the 
science, tubercle must be considered as the result of a modifi- 
cation or perversion of secretion, which is often attended or 
preceded by an active sanguinous congestion. This is all we 
know for certain ; beyond this, every thing is mere con- 
jecture. 



SECOND GENUS. 



SUBSTANCES OF A GELATINOUS APPEARANCE. 

It is not uncommon to find in different organs a substance 
which, in its physical properties, may well be compared to a 
strong animal jelly, or to a solution of starch. In consequence 
of this resemblance to jelly or glue, it has received from Laen- 
nec the name of colloid substance. Sometimes it is colourless, 
and sometimes it presents various tints from a bright yellow to 
a pale rose colour. It is without any trace of organization, 
and appears to be separated from the blood, and deposited in 
the different organic, textures. Sometimes it is infiltrated into 
them, producing more or less alteration in their appearance ; 
and sometimes it is collected into one or more isolated masses, 
which seem, when depositing, to have thrust back the sur- 
rounding parts : in both cases it is similar in its effects to pus 
or tubercle. When it exists in the state of infiltration, it often 
happens that the cellular tissue, whose areolae it fills, becomes 
indurated around the molecules of the effused matter. In 
such cases, whether the induration depends on a true hyper- 
trophy of the cellular fibre, or is merely the result of a mechan- 
ical condensation, the jelly-like substance is always traversed, 
and divided Into compartments by numerous white, hard, re- 
sisting plates, which seem to have the office of secreting it. 



LESIONS OF SECRETION. 329 

In some cases these plates tend to pass into the fibrous or car- 
tilaginous state ; and red vessels have been observed ramifying 
on their surface, but never have, to my knowledge, been traced 
into the colloid matter itself. 

The colloid substance does not exist in this isolated state 
only ; it is also found at times in tumours composed of a medley 
of different morbid products. It is not uncommon to find de- 
posits of it in the midst of tumours formed of cellular tissue in a 
state of hypertrophy or induration ; and it is often contained in 
cysts of various kinds, which appear to be its secreting organs. 
The tumour described by authors under the name of meliceris, 
which consists of a cyst containing a fluid like honey, is, in my 
opinion, merely a variety of the morbid production at present 

under consideration. 

If I may draw a conclusion from a single instance, I am au- 
thorized in admitting that this same morbid secretion whose 
numerous varieties resemble animal or vegetable jelly, glue, or 
honey, respectively, may be formed not only in the different 
organic tissues, with or without a cyst, as we have just seen, but 
also in the interior of the great serous cavities. I allude to a 
case in which I found one of the pleura) full of a slightly greyish 
substance, exactly resembling honey ; so much so indeed, that 
I find it designated in my notes by the name of meliceris in- 
terne. 

I refer the reader to the article Transformation, for the de- 
scription of some cases of developement of the colloid sub- 
stance ; which will serve to complete its history as far as can 
be done in the present state of the science. 



THIRD GENUS. 



FATTY SUBSTANCES. 

The fatty substances developed in different parts of the sys- 
tem may be divided into two species, according as they are per- 
Vol. I. 43 



330 LESIONS OF SECRETION. 

fectly identical in their physical and chemical properties with 
natural fat, or as they are more or less removed from it. 

The first species is, most commonly, not a new production, 
but is merely the natural fat secreted in greater quantity than 
usual. It has been already spoken of in the first chapter of this 
section. 

The second species does not resemble the natural fat in ap- 
pearance, although it does in its principal component parts, 
without which it would not be fat. Thus, there are sometimes 
found, in different parts of the body, cysts of various sizes, filled 
with a substance exactly similar to suet, which sometimes con- 
stitutes of itself the entire bulk of the tumour, and sometimes is 
mixed with different other morbid secretions, or alterations of 
nutrition. It is not very uncommon to find in the ovaries, 
tumours formed wholly or partly of a fatty matter like suet. I 
have elsewhere (Clinique Medicale) mentioned a case of a cyst 
with cartilaginous parietes, of the size of the head of a full- 
grown foetus, developed between the folds of the mesentery, 
and full of a suety matter. Hair has not unfrequently been 
found in such tumours. 

We sometimes observe the proper tissue of the different 
parenchymatous organs reduced to a state of atrophy, and its 
place occupied by a fatty matter, easily recognizable by its 
physical properties. It is then said that these textures are 
transformed into fat. I shall follow in detail the effects of this 
alteration on the different organs, when I come to treat spe- 
cially of the morbid anatomy of each. 



FOURTH GENUS. 



SALINE SUBSTANCES. 

Chemical analysis has detected in all the animal fluids the 
presence of a certain number of salts analogous to those form- 
ing a great part of the inorganic kingdom. It often happens 
that, under the influence of causes which are still far from be- 



LESIONS OF SECRETION. 381 

Ing well known, these salts are formed or deposited in supera- 
bundant quantities in different parts of the body. There is not 
a single part of the system where such saline concretions have 
not been discovered. They may consist either of the same salts 
as are usually found in the blood and other fluids of the body, 
or of others not usually contained in them. Sometimes they 
are found in the fluids, in the excretory ducts by which they 
are to escape from the system, and they are then formed at the 
expense of those fluids; hence proceed the salivary, biliary, 
and urinary calculi, whose history will come before us in the 
second volume along with that of the organs in which they are 
formed. Sometimes, again, these deposits are formed in the 
solids, whether in the cellular tissue or in the various paren- 
chymata. They may be found either alone, or combined with 
other morbid productions. Lastly, they sometimes succeed 
other morbid secretions: thus we have already seen that tuber- 
cle is in some instances replaced by a calcareous concretion. 



FIFTH GENUS. 



COLOURING MATTERS. 

The formation of colouring matter in the tissues is one of the 
most general phenomena presented in the organic kingdom, 
vegetable or animal. The white variety of the human race is 
that in which the colouring matter least abounds, while it be- 
comes more abundant and more varied in the inferior classes 
of animals. Even in the white man, however, there are some 
traces of colouring matter or pigmentum to be found, 1. in the 
pilous system ; 2. in the choroid ; 3. in the iris ; 4. in some 
parts of the brain, where black, brown, or yellow spots appear 
in the natural condition. 

These are the only places in which deposits of colouring 
matter appear naturally in man. Perhaps I might add to the 
list, the lungs of old people. The black colour which, in them, 
tinges the parietes of the pulmonary vesicles, or the intervening 



332 LESIONS OF SECKETION. 

cellular tissue, is so common, and seems so independent of any 
morbid alteration, as to warrant the opinion of its being a 
physiological condition. It may be asked whether this secre- 
tion of colouring matter in the lungs of old people is to supply 
the place of the secretion of the pilous system which then 
usually ceases to exist ; whether it depends in any manner on 
some modification in the structure of the lungs ; or on an in- 
crease in the varying quantity of carbon separated from the 
blood at different periods of life. I must refer for the dis- 
cussion of these questions to my second volume, under the 
head of Diseases of the Respiratory Apparatus. 

The different varieties of colouring matter have been seen 
accidentally produced in all the tissues, either combined with 
them, or deposited on their surface, sometimes in the liquid, 
and sometimes in the solid state. They may be unaccom- 
panied by any other morbid alteration, or may co-exist with 
different lesions of nutrition or secretion. For instance, in- 
durated tissues often acquire a brown, black, or yellow tinge ; 
old cicatrices of the mucous membranes also are pretty fre- 
quently tinged with a more or less deep shade of black. Dif- 
ferent secretions, likewise, may present some accidental col- 
ouring matter ; as sometimes happens with tubercle. 

The deposition of colouring matter is very often preceded 
by an evident process of irritation. The skin affords us many 
instances of this. Thus we sometimes observe a grey, brown, 
or yellow tinge, in the place where a herpetic affection or an 
ulcer had existed, long after that affection has completely dis- 
appeared. But, deposits of colouring matter may also be 
formed in the skin without any antecedent irritation, and they 
have been seen spreading and multiplying on it without any 
other appreciable phenomenon than the mere change of colour. 
Cases have been seen in which the skin of individuals of the 
white species suddenly became partly or wholly black ; and 
others in which blacks became partly white. Now, in these 
depositions and abstractions of colouring matter, irritation plays 
at least no appreciable part ; so that we have here another 
case in which it favours the production of a morbid secretion, 
but is not its necessary cause. 



LESIONS OF SECRETION. 333 

Two kinds of colouring matter, one black and the other yel- 
low, have received particular names, and require a particular 
description. The black, or nearly black colouring matter has 
been called melanosis ; the yellow has ben lately described 
under the term of cirronosis. 



FIRST SPECIES. 



MELANOSIS. 

The name of melanosis has been given to an accidental pro- 
duction, whose distinguishing character is a black colour of 
greater or less intensity. 

Melanosis has received its name from M. Laennec, and was 
first described by him in the Bulletins de la Societe de I'Ecole 
de Medecine, (1806, No. 2,). Since that, several physicians in 
France and elsewhere have contributed observations of cases 
of this affection in different organs. In 1821, Dr. Breschet 
published some new remarks on its nature, chemical composi- 
tion, and the different dispositions it affects in the different 
parts of the body in man and in beasts. Lastly, MM. Trous- 
seau and Leblanc have by their late researches added a new 
interest to the history of melanosis. (Archives de Medecine, 
June, 1828). 

Melanosis may exist in four forms. 1. It pretty frequently 
constitutes masses encysted or otherwise. 2. The matter 
which composes it may, like the tubercular matter, be infiltra- 
ted into the different tissues. 3. It may be spread like a layer 
of greater or less thickness on the free surface of the mem- 
branous organs. 4. Lastly, it may exist in the fluid state, 
either pure or mixed with other fluids. Laennec has admitted 
the first three species, but says nothing of the fourth, nor in- 
deed could he, since calling melanosis, as he did, a tissue, he 
could not consider a fluid as such. But to those who view it 
in another light, and consider it merely as an unorganized de- 
posit of colouring matter, it is as easy to conceive its being in 



334 LESIONS OF SECRETION. 

the fluid as in the solid state. Be it as it may, I shall now pro- 
ceed to describe these four principal forms, in which, in my 
opinion, melanosis may indifferently appear. 

A. Melanosis in masses. This first form has also been de- 
nominated melanic mass, or concretion. These masses have 
been classed by Laennec among the accidental productions 
which have nothing analogous to them in the healthy state ; 
and, according to him, present two periods or stages of exist- 
ence : 1, a state of crudity, and, 2, a state of softening. 

In their crude state they present the following anatomical 
characters. Their colour is not always exactly the same : 
some are of a yellowish brown, so as not to answer well the 
name of melanosis ; others, like bistre ; others again, like soot ; 
lastly, others are of a fine deep black, and when rubbed on 
linen or white paper, stain it like indian ink. Their form is 
sometimes spherical, and sometimes irregular, so as not to be 
like any geometrical figure. Some melanic masses are stud- 
ded with asperities, or with small knobs, or have an embossed 
appearance ; others have a pretty strong resemblance to black 
currants, or mulberries ; lastly, others, instead of presenting a 
uniform appearance, and consisting of one piece, are divided 
into lobules separated by cellular tissue, or else seem formed 
by an assemblage of plates or leaves lying over one another, 
or side by side. 

The consistence of these masses may, in many cases, be 
compared to that of suet ; and in others to that of the lym- 
phatic ganglions. 

Their bulk varies in general from the size of a grain of mil- 
let, or of a pea, to that of two hen eggs taken together. They 
have sometimes, however, been seen much larger; for instance, 
they have been found in the abdomen in horses constituting 
enormous tumours that weighed so much as six-and-thirty 
pounds. But such masses as these are generally composed of 
several smaller masses, which, after having been formed sepa- 
rately, have subsequently grown together and become more or 
less perfectly confounded. 

According to Laennec a period at last arrives when these 
masses lose their consistence, and begin to soften from their 



LESIONS OF SECRETION. 335 

centre to their surface. When the softening is but a short way 
advanced, the masses still preserve their form ; but, on incision 
or pressure, there oozes from them a reddish, brown, or black, 
fluid, in which are suspended a greater or less number of black 
clots. At a more advanced period, they lose their consistence, 
and are transformed, at first partly, and then wholly, into a 
kind of blackish pulp. Around this, is then set up a process 
of inflammation, for the purpose of eliminating it from the sys- 
tem ; for softened melanosis, like foreign bodies, has a tenden- 
cy to make its way out of the body ; and, according to the 
situation it occupies, this is accomplished with more or less 
facility and speed. In its place there then exists an ulcerous 
cavity, which, according to its situation, the organ in which it is, 
and the constitution of the individual, may extend, remain sta- 
tionary, or proceed to cicatrization. 

Such is the description which is generally given of the stage 
of softening of melanosis. But, in the first place, we must ob- 
serve, that this softening is of very rare occurrence. Laennec 
says (Traite de V Auscultation Mediate, vol. 1. p. 293), that he 
has never himself found in the lungs cavities formed by soft- 
ened melanosis ; but cites, as instances of it, the cases xx and 
xxi in Bayle's work on phthisis pulmonalis. In both these 
cases, the pulmonary parenchyma, which was hard and black, 
contained a number of small cavities whose parietes were 
lined with a layer of pus. I do not think there is any proof 
that these cavities were produced, as Laennec imagines, by 
the softening of a melanosis ; since there was no trace of that 
accidental production in their interior : they might just as well 
have been considered as caused by the softening of small iso- 
lated tubercles, or by partial dilatations of the bronchia. In 
fact, I have often met with such cavities as those described by 
Bayle, situated, like them, in a hard black pulmonary tissue ; 
and have been as often convinced, by dissection, that they 
were merely dilated bronchia. I am stronly inclined to think, 
that what has been called the softening of melanosis, depends, 
in certain cases, simply on the softening of the natural or acci- 
dental tissues with which it was united or combined. 

There are cases in which the different lobules that often 
compose the melanic mass are not all of equal consistence. 



336 LESIONS OF SECRETION. 

Some of them do not even preserve the solid form, but resem- 
ble a thick soup of a more or less deep shade of black ; while, 
in other parts of the tumour, there is nothing to be seen but a 
black liquid contained in a sac with cellular parietes. M. Trous- 
seau adduces some facts of this nature for the purpose of dem- 
onstrating the softening of melanosis ; but the question seems 
very difficult to decide : we may just as well imagine these fluids 
to have been secreted in that state, without ever having been 
harder. Such an opinion would be the more admissible, as, from 
some cases to be cited farther on, there is little room to doubt 
that melanosis is often secreted in the liquid form in the structure, 
or on the surface of the tissues, and continues there as such. 

The masses of melanosis may either be contained in a cyst, 
or not. The first case is infinitely rarer than the second. Up 
to 1819, Laennec had found encysted melanosis only in the 
liver and the lungs; and that but once in the latter situation. 
M. Breschet asserts that he has discovered encysted melanic 
masses in different parts of the cellular tissue. Every time 
that I had an opportunity of examining masses of melanosis, 
I have invariably found them without a cyst: sometimes they ad- 
hered very closely to the surrounding tissues, and sometimes they 
were less strongly united to them, and could easily be detached 
altogether from them without being torn. Authors who assert 
that they have found these masses contained in a cyst, describe 
it to be of a cellular texture, and have never seen it of a fibrous, 
cartilaginous, or osseous nature. By its external face, it ad- 
heres loosely to the tissues with which it happens to be in con- 
tact; from its internal, it often seems to send very delicate 
processes into the substance of the melanic concretion. 

All attempts to seek for any trace of organization in melanic 
masses would be useless. They present merely a homogene- 
ous mass, sometimes divided into lobules or plates by some 
cellular tissue, which traverses its substance without belonging 
to it. Neither cavities, nor areolae, nor fibres, are to be found 
in them; nor are any vessels or nerves distributed to them: in 
short, they are real inorganic productions, and seem to have no 
claim whatever to the name of tissue. I am of opinion, there- 
fore, that authors have not been correct in calling melanosis an 



LESIONS OF SECRETION. 337 

accidental tissue; it is no more such than tubercle, and, as in 
the case of the latter, if vital phenomena sometimes appear in 
the midst of a melanic mass, it is quite certain that they take 
place in the living parts involved and confined in that mass. 

B. Infiltrated melanosis. Writers have described under this 
name the black induration of certain organs, especially of the 
lungs and lymphatic ganglions. This induration, say they, re- 
sults from the presence in the lungs, or other organs, of a new 
tissue, which is united or combined, molecule to molecule, with 
the tissue of the organ itself. We can conceive this to be the 
case in some instances; and that the colouring matter consti- 
tuting melanosis may be deposited and become solid in each of 
the cells or areote of the parenchyma, thus producing an ap- 
pearance of induration of this latter, just as we have before 
seen it forming a solid deposit in a circumscribed point, and 
constituting a melanic mass of concretion. I think, however, 
it would be easy to prove that, in most cases, the induration of 
an organ which becomes black at the same time, has no con- 
nexion with this black colour, but is the simple result of a 
chronic phlegmasia. Such is the case, for instance, with the 
black induration of the lungs, which constitutes the phthisis 
with melanosis of Bayle. 

In fact, the same induration of the pulmonary parenchyma 
may be found accompanied with all possible colours, red, bright 
grey, deep grey, or slate colour. In some cases, we can ob- 
serve in the same lung the transition, by almost insensible 
gradations, from the grey tint to the deepest black; and the 
lung is equally hard where it is not black. We must, there- 
fore, conclude, that the state of induration of the lungs accom- 
panied with a black tint, does not differ essentially from that 
accompanied with a whitish or greyish tint. In the latter case, 
we at once refer the pulmonary induration to a simple chronic 
inflammation: why, then, should we not regard the black indu- 
ration as depending on the same cause? A simple shade of 
colour is certainly not sufficient to warrant us in considering as 
different two states which exactly resemble each other in every 
other respect, both in their anatomical characters, in the symp- 
toms that announced them during life, and in the causes which 
Vol. I. 44 



338 LESIONS OF SECRETION. 

produced them. Thus, then, we must either regard the phthisis 
with melanosis of Bayle simply as a variety of chronic pneu- 
monia, or we must enlarge the number of phthisical affections, 
and refer to them as so many distinct species, the white, grey, 
and yellow induration of the pulmonary parenchyma. In some 
cases, we find, scattered through a generally sound lung, some 
hard black masses, which at first sight appear not to belong to 
the pulmonary tissue; but if, without cutting or tearing, we 
isolate from the rest a lobule containing one of those masses, 
we perceive that it is partially or wholly indurated, and of dif- 
ferent colours ; grey in many points, brownish in others, and 
quite black in that point where a superficial observation would 
have led us to examine the existence of a melanic mass, which 
now appears to be what it really is, namely, a portion of the 
pulmonary tissue itself, in a state of chronic inflammation, in- 
durated, and stained black, just as the neighbouring portions, 
which are also indurated, are stained red, grey, or brown. 

If these considerations induce us to admit that the black in- 
duration of the lungs is only a chronic pneumonia, with the ad- 
dition of a colouring matter, we may conceive cases in which 
this latter may occur without the tissue in which it is formed 
having been previously indurated ; a fact which could not be 
admitted by those writers who regard the black induration as 
owing to the presence of melanosis. Laenec also has taken 
great care to make a distinction between it and the simple 
black colour often observed in the lungs in the form of lines or 
patches, without any change in the natural consistence of that 
organ. But if it is demonstrated that the induration of the 
lungs is not produced by melanosis, but merely co-exists with 
it, there are no grounds for establishing a distinction between 
the black colouring which accompanies certain pulmonary in- 
durations, and that which exists without induration, and which 
Laennec has classed separately under the name of black pul- 
monary matter. 

C. Melanosis deposited in the form of solid layers on the 
surface of membranes. This form of melanosis has particu- 
larly been observed on the free surface of the serous mem- 
branes. Thus, in persons who die of a chronic peritonitis, the 



LESIONS OF SECRETION. 339 

peritoneum is not unfrequently found lined partially or wholly 
with a solid layer of a deep black, of several lines in thickness. 
But, if we raise this layer from the surface of the peritoneum, 
we find it to have all the characters of the false membranes of 
the serous cavities, and that it differs from them only in its 
black colour : from these facts we must, I think, conclude, that 
many melanic productions ranged in this third class ought to be 
placed in the second ; since, after all, they are merely false 
membranes stained black, or infiltrated with melanosis. It is 
remarkable that this black colour of the false membranes ap- 
pears almost exclusively in the peritoneum. I have never 
found it in the false membranes of the other cavities, the pleura 
especially. 

Melanosis also occurs sometimes in the form of a solid layer 
on the adherent surface of the serous membranes. I have 
seen an instance of it in a horse : the external surface of a coil 
of intestine was covered, for an extent of five or six inches in 
length, and three in breadth, with a layer of black matter, 
about half an inch thick, and of great consistence. It was 
situated in the cellular tissue which unites the peritoneum to 
the muscular tunic. 

D. Melanosis in the fluid state. M. Breschet has designated 
by this title certain fluids remarkable for their more or less 
deep black colour, which seem to result from a morbid secre- 
tion in several organs. Thus, in certain cases of acute, and 
still more so in some of chronic inflammation, the mucous mem- 
brane of the stomach secretes a fluid whose colour has been 
compared to that of soot or chocolate ; there is often a striking 
resemblance between this fluid thus secreted by the inflamed 
stomach, and the black blood, more or less modified in its com- 
position, that is sometimes found in the cells of the spleen. 

In some cases of chronic peritonitis, I have found the serous 
cavity of the abdomen filled with a very black fluid ; but this 
case is much rarer than that in which the peritoneum contains 
a reddish liquid, which is evidently blood in a greater or less 
state of purity. 

In a case related by M. Proust, the urine appeared of a deep 



340 LESIONS OF SECRETION. 

black colour, which he attributes to the presence of new acid, 
denominated by him melanic acid. 

MM. Trousseau and Leblanc found on a horse's kidney a 
fibrous cyst of the bulk of a fist, which contained about eight 
ounces of a black fluid. 

It follows from these facts, that the black colouring matter 
under consideration may be secreted in the liquid state both in 
accidental cavities or cysts, and in the different natural cavi- 
ties ; and that, in the latter case, it is sometimes mixed with 
the fluid usually contained in these cavities, and sometimes 
takes its place. 

Chemical composition of melanosis. Melanosis has been 
studied not only with respect to its different physical proper- 
ties, but also as to its chemical composition ; and this latter 
description of researches has, in no small degree, contributed 
to our knowledge of the real nature of this accidental produc- 
tion. M. Thenard was one of the first who employed them- 
selves with the analysis of melanosis ; he found it essentially 
composed of carbon. M. Clarion has described it as consist- 
ing of albumen and of a particular kind of black colouring 
matter. M. Lassaigne found in melanic masses taken from the 
horse: 1, fibrine ; 2, a blackish colouring matter, soluble in 
diluted sulphuric acid, and in a solution of subcarbonate of 
soda, which then assumes a red tinge ; 3, a little albumen ; 4, 
different inorganic substances, such as chloride of sodium, sub- 
carbonate of soda, phosphate of lime, and oxide of iron. Ac- 
cording to M. Barruel, melanosis is chiefly composed of a de- 
posit of the colouring matter of the blood, combined with some 
fibrine, both in a particular state. There are also found in it 
three distinct fatty substances ; the first, soluble in alcohol at a 
moderate heat, and crystallizable ; the second soluble only in 
boiling alcohol, and not crystallizable ; the third, liquid at the 
ordinary temperature. M. Barruel has besides discovered in 
it a good deal of phosphate of lime, and of iron. The details 
of his analysis are to be found in the valuable memoir on mel- 
anosis by M. Breschet. Lastly, still more recently, M. Foy 
has found a portion of a melanic mass from a horse, composed 
as follows. {Archives de Medecinc, June, 1828.) 



LESIONS OF SECRETION. 341 

Albumen 15.00 

Fibrine 6.25 

A highly carbonized principle, probably altered crasssamentum 31.40 

Water 18.75 

Oxide of iron 1.75 

Subphosphate of lime 8.75 

Muriate of potash 5.00 

ofsoda *f 3.75 

Carbonate of soda 2.50 

of lime 3.75 

of magnesia 1.75 

Tartrate of soda 1.75 

100.00 

These different analyses all agree in one important point; 
which is the reason I have thought it of use to compare their 
results. They all shew that the accidental production, termed 
melanosis, is formed of the different elements of the blood, 
especially of a colouring matter which has a greater or less re- 
semblance to that of the blood, without, however, being exactly 
similar to it. It is the presence of this colouring matter, then, 
in which (from the analysis of M. Foy) carbon appears to 
predominate, that seems essentially to constitute melanosis. 
As to the different fatty matters described by Barruel, it be- 
comes a question whether they belonged properly to the me- 
lanic mass itself, or to the tissue in which it was developed, 
which was unavoidably included in the analysis. I cannot find 
that this important distinction has been attended to in any of 
the analyses. 

Melanosis considered in the different tissues. There is 
scarcely a tissue in which this accidental production has not 
been observed in some one of the forms already described. It 
does not, however, occur with equal frequency in all the tis- 
sues, nor in all the parts of the same tissue. 

Melanic concretions have been sometimes observed in many 
parts of the cellular tissue. Thus, they have been observed in 
the subcutaneous cellular tissue in the form of rounded masses 
of various sizes, raising up the skin, and sooner or later produc- 
ing inflammation and perforative ulceration. They have like- 
wise been seen in the submucous cellular tissue ; for instance, 
anatomists have often found, on the internal surface of the in- 



342 LESIONS OF SECRETION. 

testinal canal, black tumours, situated under the mucous mem- 
brane, which was thrust up by them. The tumours of this de- 
scription I have had an opportunity of examining myself, were, 
on an average, about as large as a filbert ; I have observed 
them more frequently in the great intestine than in the rest of 
the alimentary canal, and they were all hard, and without any 
apparent tendency to softening. M. Cruveilhier has seen sim- 
ilar tumours in the stomach. I have already mentioned a case 
of melanosis developed in the subserous cellular tissue, between 
the muscular coat of the intestine, and the peritoneum. Small 
melanic masses are frequently seen deposited between the 
pleura pulmonalis and the substance of the lung, which itself 
continues perfectly unaffected. I once saw a patch of a deep 
black colour, about as large as a two-franc piece, and seven or 
eight lines thick, on the external surface of the heart. On dis- 
section, I discovered that it was situated between the fleshy 
substance of that viscus, and the pericardium ; consequently, 
it was in the subserous cellular tissue. In an English Period- 
ical, (London Medical Repository, 1823,) there is an account of 
a case in which black, round, tumours, of a pulpy consistence, 
were observed projecting underneath the serous fold of the 
pericardium which immediately lines the heart; in the same 
individual, several similar tumours were observed on the exter- 
nal surface of the pleura costalis. Several authors have re- 
corded cases of melanic masses developed in the cellular tis- 
sue interposed between the muscles, or fasciculi of the same 
muscle. Lastly, M. Chomel has given us an interesting account 
of a case in which a mass of melanosis involved the fat cellular 
tissue at the bottom of the orbit. 

Perhaps we ought to refer to a cutaneous melanosis, the black 
spots which sometimes occur in the skin of whites, without any 
change in the thickness or consistence of that membrane; and 
also the black, hard, tumours, of various shapes and sizes, that 
have been observed in some cases projecting from the surface 
of the cutaneous envelope, and that have been described by 
Alibert under the name of cancer melane, and by Jurine of Ge- 
neva, under that of cancer anthracine. In the very curious 
case described and drawn by Professor Alibert, in his Nosologic 



LESIONS OF SECRETION. 343 

Naturelle, the whole skin was studded with numerous spherical 
tumours, several of which, in size, colour, and even in gloss, 
resembled black currants or juniper berries. They were slso 
black in their interior, which was very like that of a truffle. 
M. Breschet assures us that he has found in several subjects, a 
great number of small black tumours, resembling black cur- 
rants, seated in the skin, and appearing to spring from the cor- 
pus mucosum of Malpighi. In the cases related by M. Jurine, 
we first see a very black spot appearing in some one point of 
the skin. This soon becomes a granulated tumour, not very 
unlike a mulberry. At a certain period of its existence, it 
changes colour, acquires a bistre or olive tint, and at last soft- 
ens and ulcerates; and the solution of continuity which then 
takes place presents the same characters as an ordinary can- 
cerous ulcer, with respect to its appearance, progress, the symp- 
toms to which it gives rise, and the tendency of the tumour to 
spring up anew after having been removed. I do not think 
that such a morbid production as that, can be considered as a 
simple melanosis ; it rather belongs to the class of compound 
accidental productions, to be considered farther on. 

The mucous membranes present, much more frequently 
than the skin, this black colour, which, though not natural in 
man, is so in many animals. The intestinal mucous membrane 
especially presents frequent examples of this accidental black 
stain, which appears in it in the form of points, spots, or patches 
of greater or less extent. In a man who had been affected 
with chronic diarrhoea, I found the internal surface of the great 
intestine as black as Indian ink, from the caecum to the rectum. 
The colour was seated in the mucous membrane, which pre- 
sented no other alteration except a remarkable developement 
of its follicles. In this case, the mucous membrane was not 
only intimately combined with a black colouring matter, as 
appeared from its colour not being restored by maceration in 
water; but the colour was also deposited on the free surface 
of the membrane, which blackened linen when rubbed on it. 
This condition exactly resembled the natural condition of the 
choroid. Some nearly similar cases have been brought for- 
ward bv M. Billard. 



344 LESIONS OF SECRETION. 

In the case just mentioned, we see combined the two cir- 
cumstances of a black infiltration of the mucous membrane, 
and of a secretion of the same nature on its surface. These 
two may also occur separately. Thus, we sometimes find a 
black matter contained in the alimentary canal and evidently 
resulting from a morbid secretion of its internal membrane, 
which itself merely presents a red, grey, or slate-coloured tint. 
Still more frequently, we observe the membrane stained black 
without any transudation on its surface. If we examine it at- 
tentively, we find that it results from a real black injection of 
the villi, so that it is in those the secretion of the black colour- 
ing matter or melanosis appears principally to take place. I 
have observed this particularly evident in the horse. 

We must not class among the melanic affections certain 
brown or even black tumours which are occasionally found pro- 
jecting from the internal surface of the intestines, sometimes 
with, and sometimes without, a pedicle. These resemble mel- 
anic masses only in their colour, their texture being totally 
different ; as they present indubitable traces of organization. 
On dissection, we find them composed of a tissue formed of 
filaments intersecting each other in various directions, and 
leaving between them spaces or areolae into which blood ap- 
pears effused. These tissues seem composed of a true acci- 
dental erectile tissue: they are by no means common, and when 
they do occur, there are but one or two found in the whole ex- 
tent of the intestinal canal. In one single instance, I saw eight 
or ten of them on the mucous membrane of the caecum packed 
close together. These tumours evidently differ from those 
that really belong to the class of rnelanosis, in their being no 
sign of the production of a new tissue in the latter, but merely 
an infiltration, a simple deposition of colouring matter, in the 
interior or on the surface of a natural tissue. 

The melanoses which have been considered as seated in the 
serous membranes exist much more frequently in the subjacent 
cellular tissue, or else in the membranous concretions which, 
in cases of inflammation, line the free surface of those mem- 
branes. I have already mentioned some cases of this descrip- 
tion, and also some in which the serous membranes were ob- 



LESIONS OF SECRETION. 345 

served to exhale a black fluid, which had not the appearance 
of resulting merely from the exhalation of the natuaral ele- 
ments of the blood. In some instances, however, it has ap- 
peared to me that the black tinge of the serous membranes 
was seated in their own tissue: thus, in two cases, I saw the 
intestinal portion of the peritoneum strown over with numbers 
of small black spots, nearly circular, which could be removed 
with the membrane, the cellular tissue remaining untouched 
beneath : there was no trace of peritonitis. In a horse affected 
with hydrocele, the portion of serous membrane that covered 
the tunica albuginea of one of the testicles, presented a round 
spot as black as ebony, of about the size of a five-franc piece. 
Not far from this large spot were three or four smaller ones, 
of a less regular form, and rather slate-coloured than perfectly 
black. I convinced myself by accurate dissection that this 
tinge was seated solely in the serous membrane itself. 

The different tissues composing the parietes of the arteries 
have hitherto presented melanosis under two principal forms. 
1. In more or less bulky masses, deposited between the mid- 
dle and internal coats of the vessel, like the concretions of 
phosphate of lime. 2. We more frequently observe a deep 
black tinge around and at the bottom of certain ulcers of the 
internal tunic of the artery. This is even one of the cases in 
which we can most easily follow in all its stages the change 
from the red tint of the phlegmasiae to a deep black, like ebony 
or Indian ink, through the successive tints of grey, slate-colour, 
brown, and blackish. As to the black concretions situated 
under the internal tunic, they present no more traces of organ- 
ization than any of the rest of the melanic masses that have 
been examined. There is nothing to be seen but a black, ho- 
mogeneous mass, which sometimes breaks down readily enough 
under the finger, and sometimes offers a much greater resist- 
ance. I once saw one of these concretions which resembled 
a small calculus in hardness, and differed from it only in its 
colour, being black. I greatly regret it was not analyzed, 
since it might have been found to consist of a combination of 
melanic colouring matter and phosphate of lime. 
Vol. I. 45 



346 LESIONS OF SECRETION. 

I do not know any instance of melanosis having been found 
in the parietes of the veins. There is, however, a very re- 
markable fact which has been already noticed by Breschet 
and Cruveilhier, and which I think I have ascertained myself; 
namely, the occasional presence of a black matter, or, in other 
words, of a more or less fluid melanic matter, in the cavity of 
the small arterial and venous vessels. It is not merely the pa- 
rietes of the vessels that are tinged black ; for sometimes, ac- 
cording to the account of the two able observers above men- 
tioned, there can be seen in the interior of the vessel perfectly 
distinct black globules, capable of being displaced by pressure. 
Lastly, in the case observed by Dr. Halliday already cited, in 
which there was melanosis in several organs at once, we are 
informed that minute drops of a black matter were observed in 
the course of the vessels of the base of the brain, and of the 
choroid plexus, as if they had been deposited there by exhala- 
tion. In the lungs, especially when affected with melanosis, I 
have often seen on the surface of the pulmonary lobules, or in 
the interlobular cellular tissue, black lines, quite distinct from 
the surrounding tissue, and exactly resembling small blood- 
vessels. In these different cases, is the colouring matter con- 
stituting melanosis conveyed in vascular canals to be deposited 
on the surface or in the parenchyma of the organs ? 

The osseous tissue has been seldom found affected with mel- 
anosis. One of the most remarkable instances of melanic 
colouring of the bones that has been published, is that recorded 
by Mr. Halliday, in the English periqdical already cited. The 
individual who is the subject of the case was affected with 
melanosis in several organs; but, besides that, the whole ster- 
num, the anterior part of the ribs, and the greater portion of 
the parietal and occipital bones were uniformly tinged black. 
These bodies had also become more brittle than in the natural 
state : their periosteum presented no appreciable alteration. 

We have not as yet had any detailed account of an instance 
of melanosis being seated in the fibrous or cartilaginous tissues. 
M. Breschet merely says, in his memoir on this accidental pro- 
duction, that the fibrous system also may be affected with me- 
lanosis ; and he adds that this occurs especially in that portion 



LESIONS OF SECRETION. 347 

of it connected with the muscles. The English author already 
cited, Mr. Halliday, mentions, in a very vague manner, his 
having found small black tumours on the dura mater. Lastly, 
Professor Dupuy told me that he has frequently observed, in 
oxen, a black tinge in part of the dura mater that envelopes 
the spinal cord. 

Several authors have spoken of melanic masses being found 
in the muscles ; but these masses had not involved the mus- 
cular fibres themselves, but only the cellular tissue uniting 
them. 

A remarkable case of melanosis infiltrated into the proper 
tissue of the muscles has been related by MM. Trousseau and 
Leblanc. In a white horse which had a melanic tumour on 
the perineum, some of the muscular masses at the posterior 
part of the thigh were found to be much paler than in the natu- 
ral state : inferiorly, they became insensibly confounded with 
the rest of the muscles proceeding from the ischion to the 
tibia ; on the contrary, advancing upwards, they grew paler and 
paler, the cellular tissue uniting their fibres became of agreyish 
colour, and, at last, the muscular fibres themselves, which had 
become harder and more coherent, and capable of grating un- 
der the knife, assumed a tinge of the deepest black, and in this 
state proceeded to their attachment at the ischion ; still, how- 
ever, preserving their fibrous appearance. Their tissue was 
dry, and exceedingly difficult to break down ; the tendons and 
aponeuroses had alone escaped the melanic infiltration ; and 
the ischion itself was tinged black to a great depth, and was 
remarkably friable. 

Of the muscles of organic life, the heart alone has been 
found in a state of melanosis. M. Breschet once found several 
melanic masses in the substance of its parietes. I am not 
aware of there being another instance of the kind on record. 

The different parenchymatous tissues are not at all affected 
with melanosis with equal frequency. Thus, it is often found 
in the lungs, but has never been observed in the brain, although 
the latter, in its healthy state, presents in certain parts a black 
colour, which might be denominated natural melanosis. 



348 LESIONS OF SECRETION. 

I have already spoken of melanosis of the lungs, in which 
this affection certainly appears much more frequently than in 
any other organ. It may occur either without any change in 
the ordinary consistence of the lungs, or along with an increase 
of that consistence. In the first place, Laennec has classed it 
apart from melanosis strictly so called, and given it the name 
of black pulmonary matter. I have mentioned before my rea- 
sons for not admitting this distinction. 

The black tinge of the lungs, without increase of their con- 
sistence, may occur while they continue perfectly healthy in 
every other respect. Sometimes it exists only in the inter- 
lobular cellular tissue, and in such cases we often observe the 
most of the pulmonary lobules exactly circumscribed by black 
lines which mark their limits ; sometimes, again, the melanic 
tinge attacks the lobules themselves, and appears there in 
form of points or spots of greater or less extent. Properly 
speaking, it cannot be considered as constituting a morbid 
state. 

The black tinge of the lungs, with increase of their consis- 
tence, is, in most cases, as I have already attempted to prove, 
merely the same as that described in the preceding paragraph, 
accompanied by a morbid induration which is completely in- 
dependent of it. In other words, the lungs, when in a state of 
chronic irritation, become tinged with black, just as happens 
with the intestine, which, under the same circumstances, 
passes gradually from the red to a brown or even blackish 
tinge, which often pass into each other by such insensible 
gradations that it is impossible to tell where the one ends and 
the other begins. Is it not, then, equally impossible to assign 
at what shade the accidental tissue termed melanosis begins ? 

It is easy to enumerate the cases of melanosis in the liver 
that have been hitherto observed. It has been seen there as 
yet only in the form of masses of greater or less size. A case 
of this description, which we owe to Laennec, has been cited 
by M. Ferrus, (Dictionnaire de Medecine, vol. ix. p. 213,). 
Another very interesting case of melanosis of the liver has 
been published by M. Chomel, in the third volume of the 
Nouveau Journal de Medicine. I shall here give a sketch of 



LESIONS OP SECRETION. 349 

its principal features. The subject was a dancing master, 
aged fifty-two, who died in the last stage of marasmus. The 
liver filled the greatest part of the abdominal cavity ; above, it 
thrust up the diaphragm to the fifth true rib, and it extended 
below to the right iliac region; it weighed fourteen pounds 
seven ounces, French measure. Through its substance were 
scattered certain whitish tumours capable of being extracted 
from their bed by pressure (" enucleables"} and presenting all 
the characters of schirrhus. There were besides, in many 
parts of it, other tumours, which were as it were embossed, 
and hard and expressible like the first mentioned : some of 
them were of a fine black colour, others only of a deep grey. 
The largest of these tumours was of the size of a hen egg ; the 
rest were mostly of the size of a filbert. Through the liver 
were also scattered small black points, which, mixed through 
its own dull red, gave it a mottled appearance. The bladder 
and biliary ducts were filled with bile. 

Melanic masses have also been found in the breasts, where 
they seemed to occupy the cellular or adipose tissue situated 
between the granules composing the gland, rather than the 
gland itself ; in the thyroid body, and in the uterus; and, 
lastly, very frequently in the ovaries. The small black tu- 
mours observed in these last mentioned organs deserve our 
particular attention, because their habits and the different ap- 
pearances they present may serve to throw some light on the 
nature of melanosis. We often find in one or more points of 
an ovary one or more small cavities containing a little effused 
blood, which is in the fluid state, and is sometimes red and 
sometimes brown. The parietes of these cavities are lined 
with a blackish layer, which is evidently nothing but coag- 
ulated blood, which has assumed a deeper tint merely in virtue 
of its coagulation. 

But, in other ovaries, the blood contained in similar cavities 
is found to have lost its fluidity, and to be completely coag- 
ulated ; in many cases, it has become merely a little bit of 
whitish fibrine, and one would be inclined to say at first that 
the colouring matter had been absorbed ; but it is found de- 
posited on the parietes of the cavity in form of a pulpy layer, 



350 LESIONS OF SECRETION. 

of a red, brown or black colour. In other cases this kind of 
separation of the elements of the blood does not seem to have 
taken place ; and the whole cavity is occupied by a blackish 
clot, which in some parts assumes a greater degree of con- 
sistence, and is gradually transformed into a very hard, black 
concretion. We not unfrequently observe beside or around 
such a concretion a fine yellow colour similar to that which is 
found on the parietes of certain collections of extravasated 
blood in the brain. 

We can clearly follow, in these different cases, the remark- 
able modifications the blood may undergo, when, after having 
escaped from its natural channels, it remains for a longer or 
shorter time effused in the midst of the living tissues. A period 
arrives when it becomes so very unlike itself, that it may well 
be asked if the new appearance it presents is not the result of 
a real creation of new elements which did not exist in the blood 
at the moment of its extravasation. Be that as it may, in the 
case before us there very evidently results, from some such 
modification, a production of a black colour, and greater or less 
degree of hardness, exactly similar to those which, in other or- 
gans, constitute melanosis. 

The lymphatic ganglions of the different parts of the body 
are pretty frequently tinged black ; the frequent occurrence of 
this in the bronchial ganglions in particular, and the hypotheses 
by which it has been attempted to account for it, are well 
known. Melanosis of the lymphatic ganglions is usually ac- 
companied by a more or less notable augmentation of their 
volume. Writers have spoken of enormous melanic masses 
found in the pelvis and in front of the vertebral column, and 
have described them as formed by an agglomeration of strings 
of black hard bodies : I have sometimes seen these masses, and 
am convinced that they proceeded from the obstruction and 
black induration of the numerous lymphatic ganglions situated 
in the course of the principal vessels proceeding to the recep- 
taculum chyli. In fact there were some of these bodies which, 
being not yet black, exactly resembled lymphatic glands ; in 
others the black tinge appeared only in points or isolated spots. 
In like manner, an accurate dissection leads to the conclusion 



LESIONS OP SECRETION. 351 

that a great many encephaloid or tuberculous masses in the 
mesentery are also seated in the lymphatic ganglions. 

Melanosis may either exist alone in an organ, or be combin- 
ed with other accidental productions. We often for instance, 
observe it in combination with the schirrous or encephaloid 
tissues, in the liver, stomach, breasts, and testicles. Dr. Rou- 
zet has recorded a case of an ulcerated cancer of the breast, 
from which there used to flow a fluid as black as ink ; and per- 
haps the melanic massess already described as found by M. 
Chomel in a scirrhous liver, were merely scirrhous tumours 
tinged with melanosis. It is also combined sometimes with 
tubercle, but it does not give it a uniform tinge, and generally 
appears in isolated points, spots, or irregular striae. I once 
found in a person who had died of phthisis, several pulmonary 
calculi speckled with a multitude of small black spots. 

Melanosis, like tubercle and cancer, may attack a greater or 
less number of organs at the same time in the same individual. 
In Dr. Halliday's case, already mentioned, it existed simulta- 
neously in a great extent of the subcutaneous and intermuscu- 
lar cellular tissue, in the peritoneum, pericardium and pleura, 
ovaries, sternum, and in the bones of the cranium. M. Alibert 
saw a case in which it affected the skin, the cellular tissue of 
the different parts of the body, the mediastinum, the mesen- 
tery, the omentum, a great number of lymphatic glands, the 
thyroid body, and the lungs, all at the same time. (Nosologic 
Nuturdle, vol. i.) Lastly, in the individual whose case was 
published by Chomel, (loc. cit.) the liver, the lungs, and the 
cellular tissue at the bottom of the orbit, were affected with 
melanosis. 

Melanosis has been observed at all ages. I found a very 
marked black induration of the whole superior lobe of the left 
lung,. in a girl of nine years of age, that died at the Hopital des 
Enfans, under the care of M. Jadelot. At La Charite, I have 
frequently observed this same black pulmonary induration in 
persons who had not reached their thirtieth year. However I 
may safely assert that it is in old men that chronic pneumonia 
is most frequently accompanied with this black tinge ; as if 
the disposition to the formation of tubercles, so marked in 



352 LESIONS OF SECRETION. 

youth, was subsequently replaced by a disposition to the secre- 
tion of melanic matter. 

Melanosis is not an affection peculiar to man : it has, like the 
other accidental productions, been found also in several ani- 
mals, in which it attacks the same organs as in man. It has 
been most frequently observed in the horse ; probably, not 
because it is most common in that animal, but because it has 
been studied with more attention there. The lymphatic gan- 
glions are the parts that seem most subject to the affection. In 
a glandered horse, I once found the submaxillary lymphatic 
glands greatly indurated, increased in size, and of a fine black 
colour. Now, we know that these glands are almost always 
in a state of chronic irritation in cases of glanders ; so that 
there was here probably nothing but an ordinary ganglionitis, 
accompanied with an accidental deposition of colouring matter. 
In another horse, I found some groups of lymphatic ganglions 
in front of the bodies of the vertebrae, in a state of obstruc- 
tion, and as black as charcoal. M. Gohier, Professor at the 
veterinary school at Lyons, has found in the horse melanic 
masses in the substance of the parietes of the heart, in the 
lungs, the spleen, and even in the interior of the spinal canal. 
M. Rodet, a veterinary surgeon, has seen in a horse six years 
old a black induration of more than one half of one of the par- 
otid glands. The same horse had a considerable melanic tu- 
mour around the margin of the anus, and the bronchial gan- 
glions were also black. He likewise found in a glandered 
mare another, very remarkable, kind of melanosis, seated in 
one of the eyes : the space usually occupied by the vitreous 
humour was filled with a fluid as black as Indian ink, in which 
floated equally black clots. The crystalline lens, which ad- 
hered strongly to the posterior surface of the iris, was of a 
deep yellow colour, and in some parts, even brown.* 

It is a very remarkable circumstance in the history of mel- 
anosis as affecting the horse, that it is particularly in white or 
dapple grey horses that this accidental production has been 



+ Journal de Medecine Vrterinaire, by M. Dupuy, vol. ii. page 273. 



LESIONS OF SECRETION. 353 

observed ; as if the colouring matter, not being secreted in the 
integuments, was formed in a more or less modified state in the 
internal organs. But perhaps we have been too hasty in gener- 
alizing this fact: at least it is certain that it is not without excep- 
tions. M. Rodet has published (loc. cit.) some very interesting 
cases of melanosis in horses of all colours; and I have myself 
found it in bay horses. 

The other animals in which melanosis has been observed, are, 
according to M. Breschet, the dog, the cat, the rabbit, the 
mouse, and the rat. 

The symptoms to which this affection gives rise, have noth- 
ing peculiar about them. They appear to depend, 1. on the 
chronic irritation which so often accompanies it, whether as 
cause or effect; 2. on the simultaneous existence of other acci- 
dental productions; 3. on the uneasiness mechanically produced 
by its presence in more or less voluminous masses, from its 
compressing, like any foreign body, the parenchyma of the. 
organ in which it is developed. When none of these three 
circumstances occurs, melanosis may arise and become devel- 
oped in a tissue, without its existence being revealed by any 
symptom, any morbid phenomenon local or general. 



SECOND SPECIES. 



CIRRONOSIS. 

It has long been remarked that yellow spots sometimes ap- 
pear either on the skin, or in other membranous or parenchy- 
matous tissues; and the learned Professor Lobstein,of Strasburg, 
has lately observed in several embryos a very marked golden 
yellow tinge in different parts. He has given to this singular 
affection the name of cirronosis, (from xippog, yellow.) 

The serous membranes of the cranium, of the thorax, and 

of the abdomen, the spinal cord, and the two cords of the great 

sympathetic, are the principal parts in which M. Lobstein has 

found this affection. None of the foetuses in which he found 

Vol. I. 46 



354 LESIONS OF SECRETION. 

it were fully grown: one of them was but three months old; 
and several others had reached the fifth month of their in- 
tra-uterine existence. (Repertoire d' Anatomie Pathologique, 
vol. i.) 

It appears to me that cirronosis diners only in situation from 
the disease long known by the name of icterus infantum or 
neonatorum, in which it is any thing but proved that the yellow 
tinge of the skin is owing to the bile. 



SECOND CLASS. 



MORBID SECRETIONS SUSCEPTIBLE OF ORGANIZATION. 

I have already pointed out the nature and character of the 
substance denominated fibrine, and shown how it proceeds 
from the blood, one of whose constituents it is, and how it is 
capable of becoming organized and of preserving its vitality 
wherever deposited. We have seen how a small portion of it 
may become vascular and be transformed, sometimes into a 
tissue resembling one of the natural ones, and sometimes into 
a production equally endowed with life, and possessing a regu- 
lar structure, but yet without any thing analogous to it in the 
natural state. We have now to study this organizable sub- 
stance more in detail, and consider it in all its different situa- 
tions, whether on the surface or in the texture of the various 
parts of the body. 



FIRST ORDER. 



ORGANIZABLE PRODUCTIONS DEPOSITED ON SURFACES. 

These may occur either on the different natural surfaces, or 
on the accidental surfaces, such as those formed in every or- 



356 LESIONS OF SECRETION. 

of albumen ; boiling water caused it to shrink ; boiling alcohol 
also made it shrivel up, and dissolved a little fatty matter, 
and some chloride of sodium ; when immersed in acetic acid 
diluted with thrice its weight of water, it swells, becomes trans- 
parent, and is converted by a gentle heat into a mass soluble 
in water." 

The organizable matter of the serous cavities at first appears 
as a soft substance, without form, organization, or structure. It 
is sometimes deposited in a shapeless layer on the serous mem- 
brane, and sometimes it floats in the more or less limped fluid 
that has been secreted along with it. In other cases, it appears 
in several points at once, in the form of small globules studding 
the serous membrane, and giving it a wrinkled appearance. 
Before it has been yet organized, we see it adhering to the op- 
posite surfaces of the serous membranes, and, in order to keep 
its hold, following them as they glide over each other, and draw- 
ing out like a soft paste into filaments, lamellae, or cords. It 
sometimes disposes itself regularly enough, and forms on the 
serous membrane numerous papillae symmetrically arranged, 
or else assumes a reticulated appearance. It is a remarkable 
circumstance that the false membranes often display great reg- 
ularity in the arrangement of their particles, even before they 
have assumed any manifest characters of organization. In gen- 
eral they present an assemblage of areolae or cells whose 
parietes are formed by filaments intersecting in every direction, 
and which contain a fluid that may be expressed by a slight 
pressure. 

The false membrane, whatever be its form, gradually be- 
comes denser and more resisting, and at the same time the 
quantity of serum contained gradually decreases ; it adheres 
more and more closely to the serous membrane, and, at last, 
exhibits a phenomenon which has long attracted particular at- 
tention ; namely, its becoming injected with blood. Now the 
question is, how that fluid comes there : whether it is absolutely 
formed in the false membrane, or brought there by the vessels 
of the serous membrane, which shoot into it. Those who main- 
tain the first opinion compare these false membranes to the 
membrane of the yolk, in which both blood and vessels are like- 



LESIONS OF SECRETION. 355 

gan that has undergone a solution of continuity with or without 
loss of substance. 



FIRST GENUS. 



ORGANIZABLE PRODUCTIONS DEPOSITED ON THE NATURAL 
SURFACES. 

These are to be considered as occurring, 1. on the serous 
membranes ; 2. on the tegumentary membranes; 3. on the in- 
ternal membrane of the vessels. 



FIRST SPECIES. 



ORGANIZABLE MATTER OF THE SEROUS SURFACES. 

The numerous varieties of form which this substance pre- 
sents, have been long known by the name of false membranes. 
In fact they often bear a very great resemblance to the natural 
membrane which they line; and, in all cases, they are the seat 
of a process set up for the purpose of bringing them, by a series 
of transformations, to a state in which they shall resemble 
either a serous membrane or its subjacent cellular tissue. 

The substance constituting the false membranes of the se- 
rous cavities has long been considered as essentially albuminous 
in its nature. Albumen, however, is not, like it, capable of co- 
agulating spontaneously; which alone was sufficient to war- 
rant a suspicion that the opinion was erroneous. It has since 
been actually demonstrated that every false membrane of the 
serous cavities is composed of two parts : one, concrescible and 
plastic, formed of fibrine ; the other, fluid, and contained in the 
cells of the former, formed of albumen. M. Lassaigne has thus 
described the concrescible part: "This substance was not solu- 
ble in cold water, which merely deprived it »f a small portion 



LESIONS OF SECRETION. 357 

wise created. They also bring forward cases in which there 
are found in false membranes greater or less numbers of small 
red points, isolated from each other, which appear like so many 
small drops of blood deposited in the substance of those mem- 
branes. These points are not as yet lodged in vessels; by little 
and little they shoot out into lines or streaks, around which vas- 
cular parietes become developed, and at last, these newly 
formed vessels open into, and become continuous with, those 
of the serous membrane. On the other hand, those who main- 
tain that the vessels of the serous membrane shoot into the false 
membrane, consider the scattered red points found in it as col- 
oured globules swimming in a colourless fluid contained in a 
vessel; and assert that they have absolutely followed this pro- 
longation of the vessels from the serous to the false membrane. 
M. Gendrin has lately adduced some facts in support of this 
opinion. He says,* that "at the points where the natural and 
the newly formed membranes adhere most intimately, the se- 
rous surface is red and rugose ; the redness and rugse are ar- 
ranged in a dotted manner ; the serous surface, when examined 
with a magnifier, is found to be really covered with small red 
vascular asperities, in which, with the aid of a strong magnifier, 
or, still better, of a microscope, we can see red capillaries ter- 
minating, which are distended at the points corresponding to 
those papillae; the false membrane presents small red spots 
which evidently correspond to the rugag, each of which, at each 
of the points, penetrates slightly into the substance of the plas- 
tic matter ; for we find by the magnifier that the little spots in 
this matter are infundibuliform, and that the parietes of the 
little infundibula are lacerated. On examining with the micro- 
scope a small portion of false membrane that has reached this 
stage, we find that each of the small red infundibula serves as 
a base to one or two, and sometimes even three, yellowish, 
flexuous streaks, that take their course on the adherent surface 
of the membrane. 

" It is more easy to distinguish these first rudiments of ves- 



* Histoire Anatomique des Inflammations, vol. ii. page 551. 



358 



LESIONS OF SECRETION. 



sels, when their formation is a little more advanced. The 
rugas of the serous membrane then become more strongly 
marked ; and we can ascertain directly that they are nothing 
but vessels shooting into the false membranes." 

I shall not attempt to discuss the facts that have been ad- 
duced in support of the two opinions ; for I believe them to be 
all true. In fact, after the knowledge that has recently been 
acquired respecting the capillary circulation, it is idle to inquire 
how and where the vessels of the false membranes take their 
rise. Either in the organizable matter, or in points where it 
adheres to the serous membrane, or in that membrane itself, 
there must begin to move some glubules, which, after proceed- 
ing in various directions, and tracing out passages for them- 
selves, shall end by falling into currents already long estab- 
lished. For these phenomena to take place, it is sufficient that 
an impulse of vitality shall have been given to the organizable 
matter. This impulse once given, sanguineous currents must 
be established in it in all directions ; some arriving from the 
surrounding tissues, and others proceeding from its own sub- 
stance, and hastening to join the old currents existing around 
it. There is, then, nothing contradictory in the facts detailed 
above ; but, in my opinion, they have been ill understood, and 
wrongly interpreted, from a desire to explain the phenomena 
of the capillary circulation by those of the great arterial and 
venous circulation.* Thus, in a false membrane we may and 
ought to find, 1. some blood not contained in vessels, ar- 
ranged in dots or lines, and formed in the false membrane or 
coming from the serous membrane ; 2. vessels that do not com- 
municate with those of the surrounding tissues ; 3. others 
which do communicate with them. Moreover, according to 
the case, one or other of these dispositions may predominate ; 



* For the better understanding of what has been said, I beg to refer the reader 
to the note at page 2S3 of this volume, and, what he will find still more satisfac- 
tory, to a very interesting work by Dollinger, on the circulation of the blood, 
translated in the ninth volume of the Journal des Progres des Sciences el Institu- 
tions Medicates. 



LESIONS OP SECRETION. 359 

but they all can occur, and so far are they from being inconsist- 
ent with each other, that the existence of any one of them in- 
fers that of both the others. 

The period at which the false membranes become vascular 
is very variable : they are sometimes traversed by multitudes 
of vessels in only twenty-four hours after the commencement 
of their formation ; in other cases, there is not the slightest 
trace of vascularity at the end of several months. 

One of the most remarkable instances of the rapidity with 
which vessels can be developed in a false membrane, is the 
case related by Home. A man whom he had operated upon 
for strangulated hernia died in twenty-nine hours afterwards, 
having been for the last five hours of his existence without any 
perceptible pulsation. Upon opening the body, there was 
found on the strangulated coil of intestine a false membrane so 
very vascular, that both an artery and a vein were demon- 
strated in it by injection. Now these were not formed till 
after the operation ; since, at that time, the same portion of in- 
testine did not present, upon examination, the slightest trace of 
a false membrane on its surface. 

In a longer or shorter time after the establishment of a cir- 
culation in the false membranes, they are observed to lose the 
red colour they first had on becoming vascular. Their vessels 
become less apparent, and colourless, and the false membrane, 
whose organization may then be considered complete, assumes 
the exact appearance of a natural serous membrane, or of a 
portion of cellular tissue. At this stage, the false membranes 
can no longer be considered as belonging to the morbid state ; 
they no longer occasion any disorder in the functions, nor ex- 
cite any morbid sympathy. In how many subjects, for in- 
stance, do we find numerous adhesions between the pleura 
costalis and pulmonalis, without there having been any sign of 
their existence during life. More than once, too, I have found 
the circumvolutions of the intestines united by cellular adhe- 
sions, although during life the abdomen had been long free 
from any pain, or functional derangement. 

Thus, there are three states through which the organizable 
matter of the serous membranes passes in succession. In the 



360 LESIONS OF SECRETION. 

first state, it is an amorphous substance, without trace of or- 
ganization, and presenting no constant character, except spon- 
taneous coagulability. In the second, it appears on its way 
towards organization, and it is then the sanguineous currents 
become established in it. In the third, its organization is com- 
plete, and it has acquired all the properties either of the cellu- 
lar tissue, or of the serous membranes. In the second and 
third states, it may become the seat of various morbid changes. 
For instance, it often falls into a state of hyperaemia ; in other 
cases, it produces new false membranes in its turn, exhales 
blood, or secretes pus, tubercle, or melanosis. Lastly, through 
a modification of its nutritive action, it may undergo various 
transformations ; as for instance, into fibrous, cartilaginous, or 
osseous tissue. 

Some facts would lead us to conclude that the false mem- 
branes of the serous cavities may be absorbed, and disappear, 
after having existed for a certain time. Thus, M. Ribes ob- 
served that sometimes there was no trace of false membranes 
in the peritoneum to be found in the bodies of invalid soldiers, 
who had received penetrating wounds of the abdomen a long 
time before death. Beclard had an opportunity of examining 
the body of a madman, who at different periods of his life had 
given himself upwards of a dozen stabs of a knife in the ab- 
domen. In the situation of the most recent wounds the parts 
were united by false membranes of considerable size. Be- 
neath the scars of longer standing, in place of the false mem- 
branes, he found merely slender cellular frsena ; and lastly, in 
the parts corresponding to the oldest wounds, there was no 
trace whatever of adhesion or of false membrane. The fol- 
lowing fact, observed by M. Dupuytren, appears also very well 
suited to demonstrate the possibility of the disappearance of 
adhesions of the serous membranes. " An artificial anus, 
through which the faeces passed only for the space of twelve 
days, was formed in the groin of a woman who had a femoral 
hernia. The woman died in seven months afterwards ; and 
on opening the body it was found that the whole coil of in- 
testine that had been the seat of the accidental opening, and 
that was expected to be found adhering to the cicatrice, was 



LESIONS OF SECRETION. 361 

four or five inches from it. A cellular column resembling the 
isolated adhesions of the splanchnic cavities, broad at its ex- 
tremities, and narrow and almost filiform in the middle, ex- 
tended from the cicatrice to the coil of intestine, with the in- 
terior of which it had no communication."* 



SECOND SPECIES. 



ORGANIZABLE MATTER OF THE TEGUMEJNTAUY SURFACES. 

A substance capable of coagulating spontaneously is some- 
times deposited on the free surface of the mucous and cu- 
taneous membranes, as well as on those of the serous. It has 
been chiefly observed under the following circumstances: 1. 
extending in a membraniform layer over a portion of mucous 
membrane in a state of irritation ; 2. uniting more or less 
closely two opposite surfaces of a mucous, or cutaneous mem- 
brane, that have been accidentally placed in contact. 

The chemical composition of the substance that forms the 
membraniform layer is not as yet well known ; it is neither 
mucus nor albumen, these two principles not being susceptible 
of spontaneous coagulation ; at least, not in their natural con- 
dition. Its tendency to organization is much less marked than 
that of the coagulable matter of the serous surfaces. In gen- 
eral we find on the surface of the mucous membrane nothing 
but a white or grey layer of solid matter of variable thickness 
and consistence. It is as it were applied to the surface that 
has secreted it, and may be detached from it in large shreds, 
without any laceration in the tissue of the membrane itself. 
In some cases, there is secreted beneath the pseudo-membrane 
a more fluid substance, of a serous or purulerit nature, which 
produces its detachment. In others, it gradually becomes 



* Consult on this subject an excellent article by M. Villerme, in the Diction- 
naire des Sciences Medicates, vol. xxxii. 

Vol. I. 47 



362 LESIONS OF SECRETION. 

thinner and thinner, is reduced to a transparent pellicle, and 
finally disappears as if it had been gradually absorbed. In all 
this, there is generally no trace of organization to be detected. 
Indeed, we have scarcely any cases that prove that vessels 
have been observed in the pseudo-membranes of the mucous 
surfaces. I have myself so often sought for them in vain, that 
I should have been induced to deny their being ever found 
there, were it not that a gentleman upon whose observations 
we may place the greatest reliance, M. Guersent, has record- 
ed some cases, in which he saw vessels ramifying in the false 
membranes of croup, and anastomosing with those of the 
mucous membrane. 

But if this spontaneously coagulable matter has so little ten- 
dency to become organized, when extending as a membrane on 
the surface of the mucous tissue, the case is very different when 
it is secreted between two surfaces of mucous membrane or of 
skin that happen to be accidentally kept in contact, and that 
are at the same time in a state of irritation. Under such cir- 
cumstances a close adhesion takes place between the two sur- 
faces, and if we examine the nature of the substance that 
unites them, we find it composed sometimes of a dense cellular 
tissue traversed by more or less numerous vessels, sometimes 
of a true fibrous tissue, and lastly, sometimes of a tissue of new 
formation which has a more or less perfect analogy with the 
mucous or cutaneous tissue it serves to unite. Here we ob- 
serve the same developement, the same stages of organization 
as in the adhesions of the serous membranes. The vagina, 
uterus, fallopian tubes, ureters, and biliary ducts, are the parts 
where such adhesions have been most frequently observed. It 
is not uncommon to find two or more fingers thus united after 
a burn. M. Gendrin saw a case of adhesion between the skin 
of the cranium and the external ear.* It took place by means 
of a very close cellular tissue, adhering strongly to the skin, 
which itself appeared to have been converted, where the ad- 
hesion existed, into a laminated tissue of great density. 



* Op. cit. vol. ii. page 62S. 



LESIONS OF SECRETION. 363 



THIRD SPECIES. 



ORGANIZABLE MATTER OF THE VASCULAR SURFACES. 

Whenever the circulation ceases to be kept up in a vessel, 
the internal surface of that vessel tends to become the seat of 
an exhalation producing that same organizable matter of which 
we have already followed the formation on the serous, mucous, 
and cutaneous surfaces. By this means, the different points of 
the internal surface of the arteries or veins adhere to each 
other, and the vessel becomes obliterated. I content myself 
for the present with merely pointing out this remarkable fact, 
to which I mean to return hereafter, when we come to con- 
sider the Diseases of the Circulatory Apparatus. 



SECOND GENUS. 



ORGANIZABLE PRODUCTIONS DEPOSITED UPON ACCIDENTAL SUR- 
FACES. 

When any tissue has suffered a solution of continuity, from 
both surfaces of the wound exhales a matter which, like those 
we have just examined, becomes solid, organized, and vascu- 
lar, and is thus converted into a genuine tissue. Sometimes 
the new tissue is exactly analogous to the divided one ; some- 
times it merely approaches more or less to it ; and lastly, it 
sometimes continues in the state of a cellulo-fibrous texture. It 
is this transformation of a plastic matter into a tissue more or 
less analogous to the divided tissue, that constitutes cicatriza- 
tion. As for the rest, we could but repeat what we said in 
speaking of the false membranes of the serous cavities, if we 
attempted to describe the manner in which it becomes organ- 
ized ; as the phenomena are the same in both. When treating 



364 LESIONS OF SECRETION. 

of the diseases of the several organs, I shall point out the pe- 
culiarities that each of them presents, in the efforts made by 
nature to repair the solutions of continuity it may have suffer- 
ed. I shall only say at present that the process is similar, and 
the commencement the same in all ; it is uniformly a secreted 
matter that becomes solid and organized. The difference lies 
in what succeeds to this first process ; the cellulo-vascular text- 
ure, when once formed, becomes subject to different trans- 
formations, which vary with the nature of the tissue to be re- 
paired. 

It is this same spontaneously coagulable and organizable mat- 
ter, that is deposited on the internal surface of the parietes of 
certain accidental cavities. There, also, vessels are developed, 
and different tissues produced. A fibrous or serous tissue, for 
instance, is produced in such situations ; or else a tissue ap- 
proaching more or less to the nature of the mucous tissue. It 
may, however, be difficult to distinguish whether the principal 
part in the formation of these new productions belongs to a 
plastic matter deposited there, or to the cellular tissue, which, 
having deviated from its natural mode of nutrition, is trans- 
formed into other tissues. (See, above, the article on the 
transformations of the cellular tissue.) 

The deposition of organizable matter in the interior of acci- 
dental cavities, is followed, according to the case, by two dif- 
ferent results. 1. It may produce a membraniform layer, va- 
rying in its nature, that shall line the parietes of the cavity. 2. 
It may be so disposed as to give rise to the formation of adhe- 
sions tending to unite the different points of the surface of the 
cavity, and thus gradually produce its obliteration. Thus, 
around a coagulum of blood in the brain, there is first a serous 
cyst formed ; the newly formed serous membrane then ab- 
sorbs the coagulum ; this done, a little serosity is exhaled into 
the cyst for a certain period ; and at last its parietes approxi- 
mate, touch, adhere, and the whole cavity disappears. 



LESIONS OF SECRETION. 365 



SECOND ORDER. 



ORGANIZABLE PRODUCTIONS DEPOSITED IN THE SUBSTANCE OF 
VARIOUS PARTS OF THE BODY. 

These productions, infinitely varied as they are with res- 
pect to the physical appearance, have all as a common char- 
acter either a tendency to become organized or an already 
existing organization. Amidst the numerous varieties of figure, 
size, colour, and consistence, which they offer, all that seems 
particularly worthy of notice may be reduced to what fol- 
lows. 

Some of these productions are of a homogeneous texture, 
and on cutting into them, there is nothing found in their inte- 
rior but a substance of the same appearance throughout. This 
substance sometimes resembles a portion of fibrine that had 
been long coagulated, and deprived more or less completely of 
its colouring matter; sometimes it is much harder, being of the 
consistence of fibrous tissue or cartilage, and bearing a pretty 
close resemblance to the substance of a turnip. In other ca- 
ses, its consistence is much less, and, properly speaking, it 
cannot be said to be solid; still, however, it is not completely 
fluid, but resembles a piece of cerebral pulp, softened by pu- 
trefaction or prolonged trituration. 

In others of these productions, the texture is found to be 
heterogeneous; that is to say, their component particles are 
not all of the same nature, or, at least, have not all the same 
arrangement. Their structure is sometimes filamentous, and 
sometimes areolar; in other instances we find them presenting 
lobes or cells; and, lastly, in others, different kinds of canals 
affording a passage to fluids. Indeed, in almost all of them, 
there is a mixture of solids and liquids. 

The liquids entering into their composition may be either 
white, colourless, or more or less like the serum of the blood. 
In other cases they are coloured, being in fact regular blood 



366 LESIONS OP SECRETION. 

that is formed in these productions, just as we have already 
seen it formed in false membranes. It is not uncommon to 
find at the surface or in the interior of these productions (what- 
ever be their texture) certain red points, isolated from each 
other, and resembling spots of blood laid on with the tip of a 
pencil. On other occasions, we observe irregular red streaks, 
in which case the blood does not appear to be as yet contained 
in any vessels. These streaks frequently intersect each other, 
leaving in their intervals areolae of various sizes and shapes. 
At last, there appear true vessels, which may be isolated from 
the mass they traverse, by submitting it to a very gentle tritu- 
ration, or a slight washing. When thus separated, they some- 
times resemble a network of very fine hair dyed red. In some 
cases, they may be seen opening into the vessels of the sur- 
rounding parts ; but, in others, this inosculation cannot be de- 
tected, and we see well formed vessels with very distinct 
parietes, gradually losing their vascular character and becom- 
ing confounded with the reddish streaks or the irregular spots 
above described. 

Either before or after the formation of these vessels, it may 
happen that the blood is deposited in such considerable quan- 
tities in the morbid production as to produce a real haemor- 
rhage. We then find in its interior one or more collections of 
blood, like those, for instance, that are found in the brain after 
an attack of apoplexy : the effused blood may be either fluid or 
coagulated. Instead of being collected into circumscribed 
masses, the blood sometimes infiltrates the whole of the morbid 
mass, which then presents throughout a reddish tint of greater 
or less depth, and is often reduced, in some parts, or in its 
whole extent, into a kind of pulp or pap something like the red 
matter contained in the cells of the spleen when in a peculiar 
softened state. 

We are justified, then, in admitting that the morbid produc- 
tions under consideration are possessed of vitality, since they 
have the power of forming blood, and since passages for this 
blood are opened in their interior. If they are endued with 
life, they must be capable of absorbing and secreting, as also 
of growing, not by justa-position, like tubercle, but by a true 



LESIONS OF SECRETION. 367 

intus-susception. Lastly, being possessed of life and organi- 
zation, like the false membranes of the serous cavities, they 
must, like them, be susceptible of irritation and congestion, and 
of producing various morbid secretions, such as pus, tubercle, 
saline or colouring matters, &c. 

At an uncertain period after their formation, these produc- 
tions begin to experience the effects of that law by virtue of 
which the animal seconomy must make efforts to get rid of 
every foreign matter that may be injurious to it. The sur- 
rounding parts, as well as the morbid mass itself, take on them 
a state of irritation ; then commences a process of elimination, 
which effects the destruction of the morbid mass. After this 
has been absorbed or expelled, the ulcer which occupies its 
place sometimes heals with greater or less rapidity; but, too 
often it continues, or extends more and more : too often, also, 
the disposition that has caused the formation of the morbid 
production, is not destroyed by its removal, but produces 
another of the same kind either in the same place, or in other 
parts of the system. Indeed, one of the most remarkable 
features in the history of these productions, is the tendency 
they have to occur in a great many organs at once. It is often 
at the very period when one begins to be eliminated, that others 
begin to be deposited elsewhere. In other cases, it is only af- 
ter the removal of one by the knife, that this singular multipli- 
cation of the affection commences. 

The symptoms attendant on morbid productions of this class 
may be arranged, with respect to the general features they 
have in common, in the following series. 

The first series depends simply on the developement of the 
morbid production in the midst of a living tissue, and on the 
amount of vital energy consumed in this developement. From 
thence sometimes arise some local symptoms, such as pain of 
different kinds and degrees of intensity ; sometimes there is a 
complete absence of local symptoms, and merely an alteration 
in the general nutrition, gradual loss of flesh and strength, and 
some erratic paroxysms of fever. In some cases, it is impos- 
sible to discover the origin of this deranged state of health. 

The second series takes its source from the various patho- 



368 LESIONS OF SECRETION. 

logical conditions to which the morbid production itself is sub- 
ject. If, for instance, it happens to be in a state of irritation 
and congestion, we may observe during that time either an 
unusual pain, a febrile reaction, or different nervous derange- 
ments. 

The third series is connected with the state of the parts 
around the morbid production. According as they continue 
healthy or become diseased, according to the degree and na- 
ture of the affection, and according as it is acute or chronic, 
continued or intermittent, we observe different groups of symp- 
toms that do not belong to the morbid production itself. It is 
of importance not to lose sight of this circumstance, as the 
practical consequence to be drawn from it is, that when such 
symptoms appear, we may attempt to combat them, without 
seeking directly to modify the production itself. 

The fourth series begins to appear when the eliminatory 
process is going on; and consequently when the morbid pro- 
duction is near being removed. At this period the local pains 
commence or increase, a constant febrile excitement prevails, 
a considerable decay takes place, and, lastly, the blood, being 
modified in its composition, gives the skin that peculiar yellow- 
ish tinge that has been considered as characteristic of the state 
called by authors the cancerous cachexy. 

The fifth and last series of symptoms occurs along with the 
ulceration that ensues upon the removal of the morbid produc- 
tion. They vary according as the morbid growth is repro- 
duced, either in the same place or elsewhere. 

I have already said that, in the present state of the science, 
I considered it useless to attempt to designate by particular 
names the infinite variety of appearances that may be assumed 
by organizable morbid productions deposited in the texture of 
the various parts of the body. It is my business, however, in 
this place, to bring before the reader some of the names that 
have been employed, and to explain how they were applied. 

In some cases the organizable morbid production consists of 
a reddish flesh-like tumour, traversed by vessels more or less 
numerous. It cannot be better compared than to a portion of 
fibrine that had coagulated in a blood-vessel and become or- 



LESIONS OF SECRETION. 369 

ganized. This kind of tumour has been denominated by Aber- 
nethy common, fleshy, or vascular sarcoma. It sometimes 
contains cells with exceedingly vascular parietes, and filled 
with a serous fluid. In that case it is called by Abernethy, 
cystic sarcoma. He has seen other cases, in which the newly 
formed substance, instead of presenting a uniform mass, was 
composed of granules, which resembled the structure of the 
pancreas in their arrangement. Accordingly this kind has re- 
ceived from him the name of pancreatic sarcoma.* 

When the organizable morbid production appears as a grey- 
ish or whitish substance, without trace of vessels or of blood, 
and often divided into regular lobules by something like fibrous 
intersections, of sufficient hardness to grate under the knife, it 
it is called scirrhus. I have said elsewhere, that scirrhus often 
appeared to me to be nothing but cellular tissue in a state of 
hypertrophy and induration ; but it is not the less true that in 
many cases of scirrhus there is more than mere induration, 
there being especially a deposition of a morbid matter that be- 
comes solid and acquires a tendency to organization. Thus, 
according to my ideas on the subject, scirrhus is a tumour dis- 
tinguishable by certain well marked physical characters, and 
that may depend on two kinds of morbid affections, 1. on a 
simple alteration of nutrition of the cellular tissue, and, 2. on a 
morbid secretion. 
When a scirrhous tumour assumes a dead white tint, and 
blood-vessels appear in it, Laennec, instead of continuing to 
call it scirrhus, has given it the name of cncephaloid tissue in 
tlw crude state ; an improper term, inasmuch as at this stage 
there is no resemblance between the substance in question and 
the cerebral pulp. Besides, we have no proof that the semi- 
fluid matter compared with great reason by Laennec to the 
substance of the brain, and denominated by him encephaloid 
tissue in the state of softening, but which, I think, might more 
properly be called encephaloid matter, can only occur subse- 



* Melanges de Ckirurgie etrangere, published at Geneva, vol. ii. 

Vol. I. 48 



370 LESIONS OF SECRETION. 

quently to another stage in which it was hard and of a dead 
white colour. 

The encephaloid is, in fact, one of the most marked varieties 
of the organizable morbid productions. It is characterized by- 
its perfect resemblance to cerebral pulp that is just beginning 
to soften ; and generally contains vessels, or, at least, some 
blood. It is found sometimes by itself, and sometimes in the 
tumours above described ; but I know not any fact to prove 
that they are transformed into it. It is a substance deposited 
in the midst of another ; not, as is asserted, one and the same 
production, that has passed from a state of crudity to a state of 
softening. 

It is this same substance that has been described by some 
authors under the name of medullary sarcoma. 

As to fungus Iicematocles, in my opinion, it is a generic term 
comprehending several morbid productions of different kinds. 
Thus we have already seen (page 133 of this volume) that the 
name of fungus hsematodes is often given to a developement 
of accidental erectile tissue. But the same name is also applied 
to tumours composed of sarcomatous, scirrhous, or encephaloid 
matter, especially the latter, of considerable vascularity, and 
with effusion or infiltration of blood in the interior. These are 
the same that have been also described sometimes by the name 
of vascular sarcoma. In order to prove the identity of those 
tumours, I shall content myself with transcribing the descrip- 
tion given of fungus hsematodes by Mr. Wardrop.* 

"This morbid excrescence resembles in appearance the me- 
dullary substance ; it is chiefly formed of an opaque, whitish, 
homogeneous substance, of the same consistence as the brain ; 
after having been for a short time exposed freely to the air, it 
becomes a diffluent pulp. The consistence of the tumour is 
not the same throughout; the contained matter is sometimes 
like pap, and sometimes firmer than the firm part of a fresh 
brain. It likewise presents some varieties of colour. It very 
generally possesses both the colour and the consistence of the 



* IHclioimaiie dcs Sciences JUedicalcs, article, Fungus Hematode, by M. JBreachet. 



LESIONS OF SECRETION. 371 

cerebral substance ; in some cases, part of it is redder and more 
like flesh; lastly, in others, it might betaken for a clot of blood." 

Now, is there not the greatest resemblance between, this 
description of fungus hrematodes, and that which has been 
given of encephaloid matter, by Laennec, and of medullary 
sarcoma, by Abernethy and others? 

I have now reviewed the principal varieties of appearance 
of the organizable morbid productions, without enumerating 
cancer among them; neither have I included it among the other 
alterations of nutrition and secretion already treated of. Where 
then is cancer to be placed, and what is it? In my opinion, 
cancer is not a distinct morbid alteration, but the mime is ap- 
plied to every lesion whether of nutrition or secretion, that 
has reached the period when it terminates in an ulcer con- 
stantly extending its ravages either in depth or surface. This 
metaphorical term, then, which like that of inflammation, be- 
longs to the infancy of the science, expresses merely a termina- 
tion happening in common to several very different kinds of 
alterations. I imagine that no one at the present day can 
maintain, with Bayle and Laennec, that cancer is an alteration 
suigeneris, characterized by the presence of the scirrhous and 
encephaloid tissues, isolated or combined. In fact, on the one 
hand, it is by no means unusual to discover both these produc- 
tions in a subject, although during life there was no appearance 
of the symtoms which, according to authors, are attendant upon 
cancer; so that we have the anatomical characters of a disease 
without its symptoms. On the other hand, we often meet the 
symptoms attributed to cancer, in cases where dissection can 
discover no trace either of scirrhus or encephaloid. In fact, 
the preternatural developement of a capillary network on the 
surface or in the texture of the internal or external tegumen- 
tary membranes; a determination of long standing towards a 
portion of mucous membrane, without any real change of tex- 
ture ; a small portion of that membrane, or of the skin, in a state 
of hypertrophy ; a pimple or an excrescence on the mucous or 
cutaneous surfaces, formed merely by an expansion of the prop- 
er tissue of the membranes, without any trace of a new for- 
mation; the thickening of the cellular tissue; the infiltration of 



372 LESIONS OF SECRETION. 

its meshes by an albuminous or gelatinous matter; the red or 
white induration of the lymphatic ganglions, which has no more 
to do with accidental tissue than the red or grey hepatization 
of the lungs ; these are all so many lesions, which, equally with 
encephaloid and scirrhus, may terminate in the destruction of 
the part in which they are developed, and in the production of 
an ulcer incessantly extending in every direction: all these 
lesions, though possessed of no anatomical character in com- 
mon, may have this mode of termination in common; they all, 
in the last stage of their existence, become what is called can- 
cer. The best way, then, for the practitioner to proceed, in 
the present state of the science, is to endeavour to ascertain 
from his past experience, whether such or such a lesion seems, 
from its mode of developement, progress, or accompanying 
symptoms, local or general, likely to terminate in an ulcer 
which, instead of healing, will have a tendency to extend in 
every direction, and destroy either slowly or rapidly all the 
surrounding tissues Such a lesion, let him call cancer, not be- 
cause it consists of such or such a morbid production, but be- 
cause it tends to proceed to the termination above described, 
by producing in the system a general derangement proportion- 
ed to the severity of the local affection. 



THIRD CLASS. 



MORBID PRODUCTIONS THAT ARE ORGANIZED AND ENJOY AN 
INDIVIDUAL EXISTENCE. 



ENTOZOA. 

Under the generic term entozoa, have been designated the 
different living beings that are produced and developed within 
other living beings. The entozoa must be distinguished from 
the ectozoa; that is to say, from those living beings that are 
also found in the bodies of animals, but that have been intro- 



LESIONS OF SECRETION. 373 

duced there from without. Thus, insects or other animals may 
become lodged in the skin or under it, in the nasal fossae and 
adjacent parts, and in the stomach and the rest of the alimen- 
tary canal. At certain periods of the year, for instance, the 
internal surface of the whole of the splenic portion of the 
stomach of the horse is found covered with immense numbers 
of small worms which adhere very strongly to it, even leaving 
in the place they had occupied a slight solution of continuity, 
when detached with violence. Now, these animals are not 
produced in the stomach, but are introduced into it in the state 
of eggs along with the food. The stomach of the horse is the 
place assigned them by nature for their first metamorphosis, 
and after attaining in it their complete larva state, they leave 
it, pass into the intestine, quit the body along with the faeces, 
and having once returned into the open air, they pass from the 
form of a worm to that of the fly known to naturalists under 
the name of oestrus communis. 

Entozoa have been found in most animals. In the first 
place, they have been met with in all the mammalia from man 
down to the cetacea. The three other classes of the verte- 
brata are likewise subject to them ; perhaps, indeed, there is a 
greater number of entozoa found in birds, reptiles, and fishes, 
than in the mammalia. ■ The invertebrata have likewise their 
own entozoa ; thus, they have been ascertained to exist in all 
the classes of insects : in these, however, it is but one species, 
the filaria, that is always found. 

In all these animals, the entozoa have two distinct classes of 
habitations: 1. in the cavities; 2. in the parenchyma of organs. 
Each of them has its own peculiar habitation ; thus, the as- 
caris lumbricoides is never found but in the intestine; the 
strongylus resides chiefly in the urinary passages, the fluke 
(fasciola hepatica) in the liver, and the filaria in the cellular 
tissue, &c. 

The entozoa assume three principal varieties of form : some 
are cylindrical or fusiform ; others flat like a riband ; and, 
lastly, others are vesicular. 

Their organization is very variable. There are some en- 
tozoa that consist of nothing but a parenchymatous mass, with- 



374 LESIONS OP SECRETION. 

out any distinct cavity, or very perceptible organ. Others 
resemble simply a bladder filled with water. Besides such 
beings as these, whose rude and imperfect organization con- 
fines them to the lowest rank in the zoological scale, we find 
other entozoa possessed of a very evident muscular system, a 
complete alimentary canal, well developed organs of genera- 
tion with distinct sexes, rudiments of a circulation, and ap- 
parently even some vestiges of a nervous system. 

The entozoa have been classed by turns according to their 
habitation, their form, and their organization. 

Linnaeus chose to found his classification of the entozoa 
upon their difference of habitation, and divided them into two 
classes ; the first comprehending the worms that reside in the 
alimentary canal {vermes inlestinales) ; the second, those re- 
siding in the substance of the different organs or tissues {vermes 
viscerales.) 

Rudolphi* selected their form as the distinguishing mark, 
and has arranged them in the five following classes. 
Class I. Nematoidea. {typx, filum, afos, forma). 

These have a cylindrical or thread-like form. Their struct- 
ure is very complicated ; they are furnished with a digestive 
apparatus with two orifices, and distinct genital organs. 

The ascaris lumbricoides, strongylus, oxyuris, and trichoce- 
phalus belong to this class. 

Class II. Acanthocephala («x«v.9-«, spina, y.s6a.M, caput. 

These have a sacciform or utricular body, terminated by a 
retractile head armed with one or more proboscises and prick- 
les. They are without any trace of an intestinal canal, but 
have distinct genital organs, and a difference of sex. 

To this class belongs the echinorhyncus, found in the intes- 
tine of the hog. 

Class III. Trematoda. (^x^*, foramen; t^xtu^m, fora- 
minosus). 



* Entozoorum, sive vermiam intestirudium historia naturalis, auctore Rudolphi, 3 
vol. in 8vo. 



LESIONS OF SECRETION. 375 

These have a flattened body, remarkable for the more or 
less numerous pores on its surface. According to the number 
of these pores they have been divided into monostonia, distoma, 
tetrastoma, polystoma, fyc. They are without an intestinal ca- 
nal, and have the organs of both sexes united in the same indi- 
vidual. 

Class IV. Cestoidea. (xte-ros, cingulum, taenia, ufos, forma). 

These are distinguished by their elongated, flattened body, 
resembling a riband. It is sometimes articulated and some- 
times not. The form of the head is very variable. There is 
no vestige of a digestive tube ; in some, a few nutritive vessels 
may be traced. Ovaries are found in some species ; in others 
there is scarcely any appearance of genital organs. 

The tcenice belong to this class. 

Class V. Cystica, (mo-tis, vesica). 

These have the form of a bladder, surmounted by, or con- 
taining in it, one or more appendices. Their organization is 
still more simple than that of the tcenice. 

This class comprises the hydatids. 

M. Cuvier* has divided the entozoa into two grand classes, 
founded upon a difference in their organization. The first 
class contains all those that have a distinct digestive cavity ; 
these he calls cavitaires. The second class all those in which 
no alimentary canal can be traced in the interior of the body, 
and which in general present merely an amorphous parenchy- 
ma ; these he calls parenchymateux. 

The nematoidea of Rudolphi are the cavataires of Cuvier. 
The four other classes of the German naturalist fall under the 
second of the other. 



* Tableau du regne Jlnimal, 4 vol. 8vo. 



376 LESIONS OP SECRETION. 



Class. I. Entozoa Cavilaria. 



Character : Digestive tube very distinct, contained in an ab- 
dominal cavity ; form roundish. 

This class contains thre.,e orders, established on the differen- 
ces of form presented by the entozoa comprised under them. 

Order I. Body Cylindrical. This order chiefly comprises 
the genus filaria. 

Order II. Body fusiform. Chiefly comprising the ascaris 
lumbricoides and the strongylus. 

Order III. Body more slender towards one extremity than 
towards the other. This is the case sometimes towards the 
head, as in the trichocephalus ; and sometimes towards the 
tail, as in the oxyuris. 

All these entozoa have the same organization. It has been 
particularly studied in the ascaris lumbricoides, and the obser- 
vations I am now going to make on the organization of this 
genus are applicable to the rest. The detailed account of each 
will be given in the second volume, in treating of the different 
organs it chiefly infests. Thus, the trichocephalus will be de- 
scribed in the article on the diseases of the alimentary canal ; 
the strongylus in that on the diseases of the urinary pas- 
sages, &c. 

In the ascaris lumbricoides we find an external integument, 
muscles, a digestive apparatus, and genital organs. It is even 
supposed that traces of a nervous and of a circulatory system 
have been discovered in it. The organs of digestion and of 
generation, are bathed in an unctious fluid, secreted in the inte- 
rior of a great cavity in which they are contained. 

Immediately beneath the skin, the muscular apparatus forms 
a general envelope for the whole animal. It is composed of 
two plates of fibres ; the one set circular or transverse, the 
other longitudinal. The arragement of these fibres is best 
compared to that of the fibres of the muscular tunic of the in- 
testines in the mammalia. 



LESIONS OF SECRETION. 377 

The alimentary canal is without any circumvolutions ; it is 
straight, and nearly as long as the body. It is distinguished 
by its generally brownish colour, depending on the matter con- 
tained. It begins by a mouth with a triangular orifice furnish- 
ed with three tubercles, disposed in such a manner that two 
are inferior and one is superior.* The mouth, which is cover- 
ed internally with small granules constituting perhaps a secre- 
tory apparatus, communicates with a duct with thick parietes, 
which, in form and situation, answers to the oesophagus. To 
this succeeds another, somewhat wider, part, which may be 
considered as the stomach ; lower down it grows narrow 
again, and becomes an intestine opening externally close to 
the extremity opposite that with the three tubercles. 

From the external surface of the alimentary canal proceed 
a great number of filaments, that swell out the culs-de-sac at a 
certain distance from the intestine. Their nature and use are 
unknown. 

The generative apparatus fills a great part of the body. We 
can perceive its numerous whitish filaments through the skin, 
and on cutting through this latter and the subjacent muscular 
fibres, the first thing that strikes us is the innumerable quantity 
of these filaments, which appear to form an inextricable tangle 
around the alimentary canal. On a more attentive examina- 
tion, we find that they differ according to the individual in 
which they are examined, forming in some a male, and in 
others a female generative apparatus. 

The male organs of generation consist of a penis, a seminal 
reservoir, and a testicle. 

The penis is situated close to the anus, and is found protrud- 
ed or retracted according to circumstances. It is continuous 
with a straight canal with thick parietes ; this may be consid- 
ered either as a vas deferens or as a vesicula seminalis. This 
canal is succeeded by another, distinguished, 1. by its much 
greater tenuity ; 2. by its innumerable flexuosities ; and, 3. by 



* The tubercles may serve to characterize the ascaris lumbricMes, being found 
in that species exclusively. 

Voi. I. 4» 



378 LESIONS OF SECRETION. 

its terminating in a cul-de-sac floating freely in the abdomen, 
This very slender and tortuous tube, which forms by its con- 
volutions an almost inextricable knot, and is nearly three feet 
long, is evidently analogous to the testicle. In this organ there 
is no other condition requisite for the accomplishment of its 
secretion than the existence of an immense surface ; in like 
manner, in many animals the liver is nothing but an assem- 
blage of numerous canals, terminating in culs-de-sac, without 
the presence of what is called parenchyma. In fact, I am in- 
clined to think that this latter is said to exist when the tubes, 
becoming too numerous, form a still more inextricable knot, or 
a still closer network. 

The generative apparatus of the female commences exter- 
nally, by a cleft or vulva situated at the same side with the 
anus, at the distance of one third of the length of the body 
from its anterior extremity. This is the entrance to a distinct 
vagina that leads to a uterus equally well formed. This uterus 
soon divides into two long horns, which, after proceeding a 
certain distance, lose their straight direction, and become 
canals remarkable for their great tenuity, their numerous wind- 
ings, and their terminating in a cul-de-sac. Each of these 
canals is analogous to an ovary, which, like the testicle, is thus 
reduced to a flexuous cavity of immense surface. Thus, in 
the ascaris, there is apparently no great difference of form and 
structure between the organ that secretes the seminal fluid, 
and that which produces the ova; and yet what a difference 
there is in their productions ! 

M. Jules Colquet maintains that the two whitish lines observ- 
ed, one on the abdominal, the other on the dorsal surface of 
the ascaris, are rudiments of a nervous system ; and compares 
them to ganglionic nervous cords. According to the same au- 
thor, the two other lateral, slightly coloured lines, commencing 
between the inferior and superior tubercles, and terminating 
towards the tail, are vessels in which the blood or analogous 
fluid oscillates ; and there is some resemblance between the 
lateral lines and the dorsal vessel of insects. 



LESIONS OF SECRETION. 379 



Class II. Entozoa Parenchymatosa. 



Character. Digestive tube wanting. 

The entozoa comprised under this class have nothing in 
common but this single negative character, and the extreme 
simplicity of their structure, which is such that, with the excep- 
tion of some appearance of locomotive organs, there is no dis- 
tinct organ to be discovered in them.* 

Nothing can be more varied than their form : some are still 
a little elongated and rounded like the cavitaires ; others are 
flat ; and others spherodial. 

This class contains the acanthocephala, trematoda, cestoidea, 
and cystica. 

It is not my intention to say any thing at present of the 
first three of these orders, because, as the entozoa they con- 
tain infest principally the digestive organs, I shall have to de- 
scribe them in treating of the diseases of those organs, in the 
second volume. With the cystica, however, the case is dif- 
ferent, as they may be developed in all the organs indifferently. 
It will not, therefore, be amiss to give a general account of 
them in this part of the work. 

The cystica, so called from the word jcvb-th, vesica, have 
long been known under the name of hydatids. They have 
also been frequently described by the name of vesicular worms 
(vers vesiculates). I fact, their distinguishing character is a 
spherical form, either with or without appendices resembling 
heads, snouts, hooks, or pores, according to the species. 

Some kinds are found in clusters, and live in a state of ag- 
gregation like some of the polypi. 

They may occur in any part of the body. Thus they have 
been found, 1. in the different parenchymas, without a single 



* Those who wish for a detailed account of the organization of the ascaris 
lumbricoides, may consult with much advantage an excellent treatise by M. Jules 
Cloquet, entitled Jlnatomie des vers Intestinaux, 1 vol. 4to. Paris, 1824. 



380 LESIONS OF SECRETION. 

exception ; 2. in the cavities, whether mucous, serous, or vas- 
cular; 3. in the free cellular tissue interposed between the dif- 
ferent organs. 

Hydatids have been divided into two classes. Those of the 
first consist of a simple^bladder without any appendix ; these 
are called acephalocysts. The others consist of a bladder, to 
which are attached one or more appendices ; these are the 
ceplwlocysts. 

The class of acephalocysts was established by Laennec, who 
regarded as animals those productions which before his time 
had been considered simply as cysts. Whatever be the opin- 
ion adopted on this head, we must acknowledge that these 
cysts are so far remarkable, that they have no kind of connexion 
with the tissues in which they are developed, and that, without 
forming adhesions, or receiving their nutrition from the rest 
of the body, they float free and independent in a fluid of va- 
riable nature, whilst that which they contain in their interior is 
always the same. (See the observations in page '288 of this 
volume, on the animal nature of these cysts.) It is asserted 
that spontaneous movements have been observed in the aceph- 
alocysts ; it appears to me that this is one of those observa- 
tions that require to be repeated before we give them implicit 
credence. 

The acephalocysts exactly resemble a hollow sphere with 
transparent parietes, whose bulk may vary from that of a filbert 
to that of a large orange. Nothing can be more simple than 
their structure. The bladder-like sphere is filled with a colour- 
less transparent fluid, as limpid as the purest rock water. Its 
parietes are formed of a greyish white substance, generally 
transparent, but sometimes sprinkled with opaque white spots. 
I know not any thing better to compare this substance to, than 
the lammas that are detached from the transparent cornea af- 
ter several days' maceration in water. We should have but 
an inexact idea of these parietes from comparing them to a 
serous membrane : they differ very perceptibly from it. Be- 
tween the fingers, they feel tremulous like an animal or vegeta- 
ble jelly, and are tolerably elastic, without, at the same time, 
having much cohesion, so that they are readily torn by a gen- 



LESIONS OF SECRETION. 381 

tie pull. Their external surface is smooth ; their internal surface 
may be so likewise; sometimes, however, it is found studded 
with small bodies, of a white or grey colour, and more or less 
regularly rounded: these are sometimes few in number, and 
sometimes quite crowded together ; they vary in bulk from the 
size of a very small grain of millet to that of a lentil or an or- 
dinary pea. The nature of these bodies is still unknown; they 
have been considered by some as buds or even eggs that were 
eventually to become new acephalocysts. A circumstance 
that may have given some weight to this opinion is, that we of- 
ten find, inside one acephalocysts of a certain size, another 
production of the same kind, like one box contained in another. 
It sometimes happens that this second cyst encloses a third ; 
and we may even find as many as four or five thus contained 
one within the other. This singular phenomenon has been 
explained by supposing that some of those small bodies above 
described were transformed into acephalocysts, which were 
consequently enclosed within the one that produced them ; and 
as it is not unusual to find beside whole acephalocysts others 
of larger size that are torn, it was imagined that this was caused 
by the newly formed cysts, which, when arrived at a certain 
degree of developement, burst the one that produced them, 
which was called the mother cyst. This whole theory appears 
to me to be merely an ingenious mode of connecting these 
singular phenomena, or of assisting the recollection. 

When the acephalocysts are developed in a parenchyma, 
they are generally separated from it by a fluid of different 
kinds, contained in a cyst that forms around them, as it does 
around every body which by its presence tends to irrritate the 
parts in contact with it. This surrounding fluid often consists 
of pus; in other cases, it is serous, or tinged with blood; in 
others, tuberculous; and in others, cretaceous. These differ- 
ent substances, constantly increasing, naturally compress the 
acephalocyst, and may even rupture and destroy it, so as to 
leave only some scattered fragments floating through them. I 
recollect that I once found the fragments of membranes of 
acephalocysts floating thus in the midst of a vast abscess in the 
neighbourhood of the kidney. The parietes of the cyst formed 



382 LESIONS OF SECRETION. 

around the acephalocyst are either simply serous, or fibrous, or 
sometimes even partly or wholly osseous. 

The tissues in which the acephalocysts are developed may 
continue for a long time perfectly sound: thus it is not very un- 
common to find the existence of a hydatiferous cyst unattended 
by any disagreeable symptom, or any derangement of health, 
even in cases where, being developed near the integuments, 
they project out beneath them. 

In other cases, the surrounding tissues take on them a state 
of irritation, and from thence may result different fatal lesions ; 
but there may also result a solution of continuity allowing the 
acephalocysts to make their way out, and in this manner be- 
coming, in some cases, a means of recovery. The very hard- 
est parts may, under such circumstances, be perforated to give 
exit to the entozoa. A man was taken in at La Charite, who 
had over one of the scapulas a tumour the nature of which 
could not well be determined. From this tumour proceeded 
a great number of acephalocysts. The patient having died, a 
cluster of these entozoa was found lodged in the infra-spinous 
fossa, and another in the sub-scapular fossa ; the two clusters 
communicated with each other through a hole wrought in 
the substance of the scapula not far from its spine. 

When the acephalocysts leave the spot in which they were 
developed, they may be removed immediately out of the sys- 
tem, through a fistulous passage of greater or less length, ter- 
minating on the cutaneous surface. In other cases, they reach 
some mucous surface, from whence they may subsequently be 
eliminated in the same manner as in the preceding case. 
Thus, fragments of acephalocysts that had been developed in 
the kidneys have been known to be voided with the urine ; 
others, that had been produced in the lungs, or even in the 
liver, have been expectorated ; and others again, vomited or 
passed by stool. Lastly, these acephalocysts sometimes hap- 
pen to fall into a serous cavity, and thus produce on a sudden 
the most serious consequences. 

The cephalocysts differ from the preceding class, in that the 
bladder constituting the greatest part of their body is sur- 
mounted by one or more appendices, termed heads. Some- 



LESIONS OF SECRETION. 383 

times there is but one, sometimes two or more : hence they 
are divided into monocephalocysts and polycephalocysts. 

The monocephalocysts comprehend a species of entozoon 
generally designated by the name of cysticercus {vesica cau- 
dalis), which is distinguished by the following characters : it 
consists qf a bladder, usually of small size like that of the 
acephalocysts, from one point of which rises a small appendix 
of a dead white colour, which is sometimes found protruded 
from the bladder, and sometimes retracted within it. The 
latter case is the most common, and the cysticercus then re- 
sembles a small acephalocyst with a point of a dead white 
colour in its interior. It is asserted that spontaneous move- 
ments have been observed in the cysticercus ; that it has been 
seen alternately protruding and retracting its head ; so its 
claim to the rank of an animal seems much less doubtful than 
that of the acephalocyst. 

The cysticercus has been discovered in the most different 
parts of the body both in man and in animals. 

In man, it has been found in the substance of the brain, in 
the choroid plexus, (in which situation it must not be con- 
founded with the serous cysts so frequent there,) in the lungs, 
and in the muscles. It is very common in the omentum of 
rabbits, and it has been found also in the sheep and in the ox. 
Lastly, in that disease to which pigs are subject, known by the 
name of measles, the most general and constant lesion ob- 
served is the simultaneous existence of great numbers of 
cysticerci in most of the tissues. The free cellular tissue in- 
terposed between the different organs is particularly infested 
with them, on such occasions. In two measly pigs I had an 
opportunity of dissecting, I found cysticerci, 1. in the subcu- 
taneous and intermuscular cellular tissue, where they were 
exceedingly abundant; 2. in the different folds of the perito- 
neum ; 3. in the liver ; 4. in the lungs ; and 5, in the sub- 
stance of the heart. 

Among the polycephalocysts are comprized, 1. the ditrachy- 
ceros, a species that has been found in the intestines of animals, 
and sometimes even of men ; and 2. the polycephalus, which is 
produced chiefly in the brain in sheep, and which is supposed 



384 LESIONS OF SECRETION. 

to be the cause of the disease called the staggers, to which 
these animals are subject. (For their history, see volume the 
second.) 

After having thus given a rapid sketch of the entozoa, we 
must confess our complete ignorance with regard to the causes 
of their formation. In this case, as in that of all other produc- 
tions that have come before us, irritation may sometimes give 
rise to them, solely, however, by deranging the natural mode 
of nutrition or secretion ; so it is merely an accidental agent in 
the business. It is remarkable that the entozoa have a pe- 
culiar tendency to be developed and to increase when the ex- 
ternal agents to whose influence the subject happens to be ex- 
posed are such as tend to prevent the complete developement 
of the process of nutrition in the different tissues ; as if, under 
such circumstances, the organic particles, thus prevented from 
being completely assimilated, proceeded to arrange themselves 
so as to produce an inferior being, an entozoon. In fact, it is 
in moist countries that entozoa, the intestinal species especially, 
are most common in man ; "and it is in these countries partic- 
ularly that we observe in a great many affections, what is 
called by authors complicatio verminosa. As to animals, we 
may create entozoa in them in a manner at will, by exposing 
them to the influence of great damp, and depriving them of in- 
solation and exercise. It is thus the cysticerci become very 
numerous in the rabbits that are confined in damp coops, with- 
out sun and air. In like manner, it is probable that the 
measles in pigs depend on the damp, confined habitations, in 
which they are usually kept. A species of the trematoda, the 
distoma hepaticum, is produced in sheep that are pastured for 
a certain time in very wet grounds, where they are often in 
water half way up their legs, and where, at the same time, the 
herbage they feed on is too watery. But, why are some in- 
testinal entozoa (as the ascaris lumbricoides, and the trichoce- 
phalus) much more common in children than in adults ? How 
does it happen that, in Paris, this same ascaris, and still more, 
the taenia, are found much more frequently in the dog than in 
man ? And why does one particular species, the filaria 
Medinensis or dracuncidus, form a singular exception to the 



LESIONS OF SECRETION. 385 

habits of the rest, being the only one that is found exclusively 
in dry and torrid countries ? 



CHAPTER IV. 



Gaseous Secretions. 



Physiologists have proved that gases are exhaled by several 
membranes while in the natural state. In the first place, there 
is a continual exhalation of some kinds from the cutaneous sur- 
face. Besides the gases introduced into the alimentary canal 
from without, or formed in it by the mutual chemical action of 
the various substances taken as food, there are also some that 
are furnished directly by the mucous membrane lining the in- 
ternal surface of the stomach and intestines. Lastly, the learn- 
ed and ingenious researches of M. Edwards* leave no doubt 
that the mucous membrane of the air passages exhales, besides 
the aqueous vapour, carbonic acid and azote, the quantity vary- 
ing according to the difference of age, season, and climate. 
There are some animals provided with an organ for the express 
purpose of secreting gas: such are those fishes that have an 
air-bag or swimming-bladder. 

It is highly probable that, in a great many diseases, the gases 
that should naturally be secreted from the skin, and from sev- 
eral portions of mucous membrane, are modified both as to 
their quantity and quality. In this respect, there is still room 
for researches of importance. It is very evident, however, 
that the mere circumstance of the gaseous secretion being 
modified might well be the cause of different morbid states. 



* De V Influence des Agens physiques stir la Vie, 1 vol. 8vo. 
Vol. I. 50 



386 LESIONS OF SECRETION. 

Who can tell but that it is of the greatest importance for the 
proper discharging of more than one function, that the quantity 
of hydrogen, azote, oxygen, or carbon, which escapes from the 
body in the state of gas, should escape only in certain quanti- 
ties both absolutely and relatively? The great frequency of 
that dreadful disorder, the gravel, in cold, damp climates, has 
been attributed to a state of irritation in the kidneys, from their 
functions becoming more active in consequence of the dimin- 
ished activity of the functions of the skin. But, in cold and 
damp climates, there is another circumstance that occurs at 
the same time with this superabundant formation of uric acid ; 
namely, a notable diminution in the quantity of azote exhaled 
from the lungs ; at least we are warranted in concluding that 
this does take place, from M. Edwards having proved such to 
be the case in the damp winter of France. Now, may not the 
excess of uric acid that is then formed in the kidneys, be formed 
for the purpose of making up for the diminished exhalation of 
azote by the respiratory passages? According to this hypoth- 
esis, the irritation established in the kidneys is only a secon- 
dary phenomenon, and we must seek for the origin and the 
real cause of the disease elsewhere than in the organ in which 
it appears wholly to reside. Thus, then, in this case, as in 
many others, the source of the disease may lie in a different 
place from that where we observe an alteration of function or 
of texture. 

The gaseous secretions, like all the rest, may present altera- 
tions some of which relate to the quantity, and others to the 
quality of the exhaled gas. Besides, it may occur, that in the 
morbid state, we find gases in certain parts where none exist 
in the healthy state. Hence arises the following division : 

First class. 
Alterations of the gaseous secretions of the natural condition. 

Gaseous secretions of the skin ~\ £ In quantity 

of the lungs > altered } 

of the alimentary canal ) \ In quality. 



LESIONS OF SECRETION. 387 



Second Class. 



New gaseous secretions produced. 

Gaseous secretions in the cellular tissue. 
in the serous cavities, 
in the uterine cavity. 
in the circulatory apparatus. 

We are completely ignorant of the causes that influence the 
production of gases in these different situations. I do not 
speak here of those cases in which the gases are introduced 
from without ; for that is not secretion. If these gaseous se- 
cretions are preceded or accompanied by any alterations of 
texture, they are such as entirely to escape our notice. The 
history of each will be given in treating of the morbid anatomy 
of the apparatus in which it is situated. 



388 LESIONS OF THE BLOOD. 



SECTION IV. 



LESIONS OF THE BLOOD. 

At a period when an exclusive solidism was the prevailing- 
theory in France, Bichat, in the introduction to his Anatomie 
generate, wrote as follows : " The humeral pathology has, no 
doubt, been carried too far ; but it is founded on truth, and in 
a great many cases, we must allow that all should be referred 
to morbid humours. This idea was in a manner lost in his 
work, without being followed up either by himself or his con- 
temporaries. The humoral theories of the preceding ages had 
led to such false conceptions of the nature of a great number 
of diseases, and still more to such fatal plans of treatment, 
that it was not surprising that every one should be on his 
guard against opinions and facts tending to attribute to the 
fluids any share whatever in the production of diseases. For 
a long period, humorism seemed to be condemned without ap- 
peal ; and the numerous facts bearing on the subject, which 
have been since again brought forward, seemed to be forgot- 
ten, or continued unproductive, nobody attempting to draw 
conclusions from them. It was, however, easy to foresee that 
the theory of exclusive solidism, after having been followed up 
through all its consequences, would eventually be rejected, in 
consequence of its being found incapable of affording an ex- 
planation of every case ; and that it would then be necessary 
to have recourse to some other system for a more satisfactory 
solution of the difficulty. This first step towards a return to 
humorism is, therefore, but a natural consequence of the pro- 
gress of the spirit of science, and should be viewed and re- 
ceived as such. Let us then join in it, by collecting the facts 



LESIONS OF THE BLOOD. 389 

that have given rise to it, and drawing up a kind of inventory 
of all we are in possession of that bears on the subject ; and let 
us endeavour to determine accurately where we are, in order 
that we may know where we are going, to what conclusion we 
are proceeding, and how we are to arrive at it. 

The alterations of the fluids should be studied, 1. in the 
blood ; and, 2. in the different humours which concur in form- 
ing the blood, or which emanate from it. Of these humours, 
there are two especially, the chyle and the lymph, whose qual- 
ities must have a direct influence on the state of the blood. 
We must observe, however, that if the other humours happen 
to be modified in quantity, or quality, their modifications may 
infer modifications in the blood also, as their constituent prin- 
ciples proceed from that fluid. 

The blood, while circulating, seems to be under the influence 
of two forces. The one imparts to the mass an intestine mo- 
tion, by virtue of which each of its globules moves on by itself, 
surrounded by an envelope of colouring matter, and keeping 
at a certain distance from the rest. This double action of at- 
traction and repulsion ceases to take place the moment the 
blood leaves its vessels. The other force, directly opposite to 
the preceding, tends to bring the blood to a state of repose : it 
is exerted in the organic parenchymas at the point of contact 
of the solids and the blood. The blood, when examined with 
a microscope in these parenchymas, has been compared to a 
kind of whirlpool, from which particles were incessantly de- 
tached to be lost in the solid substance, whilst others were 
quitting this latter and returning into the vortex. If, then, 
there is a great difference between the blood contained in the 
large vessels and the different solids, that is by no means the 
case in the capillaries ; in these, the blood and the tissues to 
which it is distributed tend to be confounded together. At 
their point of contact, the blood assumes the nature of the solid, 
and becomes organized ; so that its vitality is no longer du- 
bious. But it is not there only that we can discover a power 
of organization in the blood ; we find it active and prolific 
wherever the fibrine coagulates, whether in the vessels or out 



390 LESIONS OF THE BLOOD 

of them. I have already shown how, under such circumstan- 
ces, vessels make their appearance in the fibrine, how a circu- 
lation becomes established, secretions take place, and tissues 
are developed m it. If we analyze the blood and the solids, 
we discover the same proximate principles in both. If we ex- 
amine their physical structure, we find it identical, both con- 
sisting of globules mixed with an amorphous substance. Bor- 
deu acknowledged this identity of composition when he said 
that blood is fluid flesh, " Le sang est de la chair coulante." 

Thus then in the three-fold respect of the vital phenomena,* 
intimate structure, and chemical composition, no line of demar- 
cation can be drawn with strictness and precision between the 
blood and the solids. Physiologically speaking, it is impossible 
to conceive that one of these two parts of the same whole 
could be modified without the other being so likewise. On 
the one hand, inasmuch as the blood nourishes the solids, and 
as without its presence they cannot support life, the state of 
the solids cannot but be influenced by the state of the blood. 
The chemist might as well say that the nature of a body does 
not depend on the nature of the elements that compose it. On 
the other hand, the solids, considered with respect to their rela- 
tions to the blood, form but two classes : the one contributing to 
make the blood, such as'those concerned in the actions of ab- 



* It is admitted that the phenomena called vital do not display themselves un- 
less in certain states of arrangement of the particles of a body, termed organiza- 
tion ; but the meaning of this last word is far from being fully determined, and 
we must not imagine that manifestations of vitality can occur only where there 
exists an organization such as is observed in the higher orders of animals, and 
such as we are accustomed to figure to ourselves as existing in every case. If 
we follow the series of living beings, we shall find the vital organs gradually di- 
minishing in number and complexity ; nay, even disappearing altogether, and 
yet life continuing. Life exists likewise in the seed in vegetables, and in the drop 
of fluid that constitutes the first rudiments of the embryo in animals; yet in these, 
we find still less appearance of what is called organization, than there is in the 
blood. We see, then, that vital actions take place without the presence of that 
peculiar formation to which common opinion attaches the idea of vitality ; so 
that observation, far from leading us to infer that certain conditions of arrange- 
ment are necessary for the manifestation of life, teaches us that in a thousand 
different cases life is revealed to us, not by forms but by acts. 



LESIONS OF THE BLOOD. 391 

sorption, digestion, arterial circulation, and respiration ; the 
other contributing to unmake it, those, namely, concerned in 
the actions of venous circulation, secretion, and nutrition. No 
one solid, therefore, can undergo the slightest modification, 
without producing some derangement in the nature or quantity 
of the materials destined to form the blood, or to be separated 
from it. Physiology, then, leads us to the conclusion that every 
alteration of the solids must be succeeded by an alteration of 
the blood, just as every modification of the blood must be suc- 
ceeded by a modification of the solids. Viewed in this light, 
there is no longer any meaning in the disputes between the 
solidists and the humorists ; the system appears to constitute 
but one great whole, indivisible in the state of health as well 
as in that of disease ; the division of the parts of the body into 
solids and fluids seems to be a distinction of small importance, 
and one that is not always just, since it ceases to exist in the 
intimate structure of the organs, in which all the grand vital 
phenomena take place, and in which also, occur all the changes 
that constitute the morbid state. 

This intimate and necessary dependence of the blood and 
solids on each other having been once taught us by physiology, 
what remains to be done ? Merely to have recourse to obser- 
vation for facts, and to draw legitimate conclusions from them. 
The plan I have adopted has led me already, at the com- 
mencement of this volume, to treat of the alterations the blood 
may undergo in its quantity, and of the morbid states produced 
by such alterations in its qualities of which the blood is suscep- 
tible, and of the influence they may have in the production of 
diseases. 

Chemical analysis has proved that human blood is composed 
of fibrine, albumen, a particular animal matter to which the 
blood owes its colour, free soda, oxide of iron and lime found 
in the colouring matter, and different salts, namely, lactate of 
soda, muriate of soda and of potash, phosphate of soda, phos- 
phate of magnesia, and carbonate of lime and of soda; all 
which different elements are in solution in a certain quantity of 
water. Moreover, recent researches have discovered in the 
blood some carbonic acid (Vogel) ; a matter very much re- 



392 LESIONS OP THE BLOOD. 

sembling mucus, found in the cells of the coagulum (Brande) ; 
an oily matter (Traill) ; an azotized fatty matter, similar to 
that of the brain and nerves (Vauquelin, Chevreul) ; a yellow 
colouring matter, resembling that of the bile and of the urine 
(Chevreul, Lassai^ne, Magendie, &c.) ; a substance analagous 
to urea (Prevot and Dumas, Vauquelin and Segalas). Thus 
then, from the analyses of the blood that have been hitherto 
made, though not near so numerous as they ought, this remark- 
able result has been obtained, namely, that the elements of 
most of the organs, and of some of the secreted fluids, are to 
be found in it. 

When blood is drawn from the vein of a healthy person, it 
separates into two parts ; the one, termed clot, solid, and prin- 
cipally composed of fibrine and colouring matter; the other 
fluid, consisting chiefly of water and albumen. The same phe- 
nomena occur in arterial blood. In like manner, in the dead 
body, we find in the different vessels coagulated fibrine either 
combined with some colouring matter, or separated from it. 
In a great many morbid states, the blood, during life or after 
death, presents different appearances that constitute in it so 
many genuine pathological states. Let us now study these in 
each of the elements of the blood. 

The fibrine may be altered either in quantity or in quality. 
In the first place, there are cases in which this principle is more 
abundant than usual, or at least in greater proportion relatively 
to the water and albumen. In such cases, the blood, when 
drawn from a vein, forms in the vessel that receives it a clot 
with little or no serum. These are however to be divided into 
two classes. In the first class of cases, the fibrine constituting 
the clot, still contains a pretty large quantity of serum, which 
may be separated from it by pressure ; in these the coagulum 
has but little density. In the second, on the contrary, the clot 
is very dense, and a little fluid albumen can with difficulty be 
squeezed out of it. In the first class the relative increase of 
quantity of the fibrine is only apparent ; in the second, it is real. 
We must take care not to confound them, as they belong to 
different states of the system. The very fibrinous blood is 



LESIONS OF THE BLOOD. 393 

commonly called rich blood : it may either depend simply on a 
vigorous constitution, or on certain morbid states. 

In place of being superabundant in the blood, the fibrine 
may, on the contrary, be quite the reverse. There are, in fact, 
some persons whose blood, when taken from a vein, presents 
but a very small coagulum in proportion to the large quantity 
of serum in which it appears. But, here likewise we must 
make a distinction. The diminution of quantity of the fibrine 
may be only apparent; as happens when its particles, being 
very strongly condensed, are much closer to each other than 
in their natural condition; the clot is then very small, and re- 
markably firm ; this occurs very often, for instance, in patients 
suffering under acute rheumatism. In other cases, the clot is 
not only very small, but also very soft; and there is then really 
a deficiency of fibrine. This may be observed in many cases 
of chronic disease, or in persons with a slender muscular sys- 
tem, and habitually pale skin. 

We learn, then, from observation, that in the same quantity 
of blood the fibrine may exist in various proportions, being 
sometimes above and sometimes below the regular comple- 
ment. Now, this fibrine is itself composed of determinate 
quantities of oxygen, hydrogen, azote, and carbon ; and if these 
elements are derived from the air and food, and are found in 
more or less considerable proportions in the different excretions, 
it is natural to suppose that they may also exist in variable 
proportions in the fibrine, and thus modify its nature ; and, in- 
deed, it is possible that their relative excess or deficiency may 
have some influence in the production of certain morbid 
states. 

The force that tends to keep the globules of fibrine at a cer- 
tain distance from each other during life, may be so modified 
as that they shall have a tendency to run together, as they na- 
turally do after death; and hence may result the spontaneous 
coagulation of the blood in its vessels during life. There have 
been too many cases of this nalure observed, for us of the 
present day to attempt to deny the possibility of its occurrence. 
Sometimes it takes place without any known cause ; and some- 
times it appears to accompany a state of irritation in the 
Vol. I. 51 



394 LESIONS OF THE BLOOD. 

parietes of the containing vessel. When the blood once be- 
comes solid, it displays indubitable symptoms of vitality: ves- 
sels are produced, and secretions formed in it ; and different 
alterations of nutrition, resembling those observed in the tis- 
sues, may also occur. If we examine whence this coagulated 
blood derives its vitality, we find that it cannot partake of the 
common life of the rest of the body, since it very often merely 
touches the surrounding tissues, without being in any manner 
continuous with them. We must therefore admit that these 
polypiform concretions, or polyjn, as they are called, may pos- 
sess a proper vitality, by means of organs they have created 
themselves. 

We have just been considering the cases in which there is 
a real augmentation of the force of aggregation that keeps to- 
gether the particles of the fibrine of the blood. In other cases 
there is, on the contrary, a diminution of this force; and the 
result is, either a less tendency in the blood to coagulate, or a 
total absence of coagulum. When there is one, it is remarka- 
bly soft, offers scarcely any resistance to the finger, and is 
converted by a slight agitation into a reddish fluid. In other 
cases, there is no coagulum, and we find the fibrine broken up 
into small fragments that remain suspended in the serum, or 
fall to the bottom of the vessel. Lastly, in other cases, there 
is not any appearance even of these fibrinous particles, but the 
fibrine is completely mixed with the serum, producing a fluid 
mass of a reddish or blackish colour. These different appear- 
ances presented by the blood when drawn from a vein, may 
be observed also in the vessels in the dead body; these are 
sometimes filled with coagulated blood of greater or less con- 
sistence, while, on other occasions, there is nothing to be found 
in the heart, arteries, and veins, but a perfectly fluid blood, re- 
sembling water charged with a red, brown, or black colouring 
matter. In such cases, it has been ascertained by chemical 
analysis that the fibrine is not absent, but that it is altered in 
its nature so as to be no longer spontaneously coagulable. In 
some few cases, I have seen the fibrine assuming still another 
appearance; instead of a coagulum, there was, at the bottom 
of the vessel, a homogeneous stratum, sometimes of a deep 



LESIONS OF THE BLOOD. 



395 



brown, and sometimes of a dirty grey, resembling bad pus 
more than blood. 

In certain cases in which the natural consistence of the 
fibrine is increased, or even without any very decided aug- 
mentation of its density, another very remarkable phenomenon 
is observed ; the portion of fibrine at top of the coagulum parts 
with the colouring matter, and forms a whitish, yellowish, or 
slightly greenish layer, that may vary in thickness from less 
than a line to some inches. This layer is known by the name 
of the buff, or buffy coat ; and although its formation may be 
more or less favoured by certain circumstances that have no- 
thing to do with the accompanying morbid state, such as the 
size of the orifice, the manner in which the blood flows, and 
the form of the vessel that receives it, yet it is not the less true 
that it can occur only in certain states of the system which I 
shall presently explain. The buffy coat is formed of pure 
fibrine, with which is mixed a certain quantity of serum, which, 
according to the researches of Dauler and of Gendrin, con- 
tains much more albumen than the serum of the rest of the 
blood. The greatest analogy exists, both in respect of appear- 
ance and of chemical composition, between the buffy coat of 
the blood and the substance that constitutes the false mem- 
branes of the serous cavities. 

The albumen, which always exists in a small quantity in the 
coagulum, and which, united with water, almost exclusively 
forms the serum, may be modified as well as the fibrine. In 
the first place, there are cases in which, in a given quantity of 
serum, the albumen is found in much greater quantity than 
usual in proportion to the water ; of this we may easily be con- 
vinced by exposing the serum to heat. The researches of 
Doctor Traill, which are confirmed by the more recent ones 
of M. Gendrin, have proved that, in the state termed inflam- 
matory, the serum of the blood contains nearly twice as much 
albumen as in the healthy state. This increase of the albumen 
may be detected simply by the touch, the serum being then re- 
markably viscid. In other cases, on the contrary, the very 
small coagulum obtained by heating the serum, the greatest 



396 LESIONS OF THE BLOOD. 

part of which evaporates, proves how much the quantity of 
albumen is diminished. 

Is it to a particular alteration in the nature of the albumen 
of the blood we are to attribute the presence of a mucous layer 
that has been sometimes observed by M. Gendrin at the bot- 
tom of the serum, or suspended in it like a cloud ? In one of 
the cases he mentions, the blood was taken from an individual 
affected with empyema ; in another, there was a vast abscess 
in one of the thighs. 

The serum, in respect to its composition, presents several 
varieties that we must not confound : 1. it may contain at the 
same time much water and much albumen ; 2. the latter prin- 
ciple may predominate, the quantity of water remaining the 
same, or even being diminished ; 3. the reverse may take 
place, and the serum be composed of much water, and little 
albumen. 

Whatever be the composition of the serum, it is sometimes 
found in small quantity in proportion to the coagulum, and 
sometimes the reverse is the case. All these differences should 
be noted, as corresponding to so manj r particular morbid states. 

It is worth while remarking, in many of these cases, how 
very just are the common expressions of impoverished blood, 
watery blood, blood turned into water, fyc. 

In some persons, the blood drawn from a vein is remarkable 
for the intensity of its colour ; in others, on the contrary, it is 
exceedingly pale, the coagulum is of a rose-coloured white, 
and the serum resembles water ; in this case the colouring mat- 
ter of the blood is either diminished in quantity, or altered in 
its nature. This in general co-exists with an increase of the se- 
rous part of the blood. The human being, in such cases, ap- 
pears in this respect to descend in the zoological scale, and his 
blood tends to become analogous to the naturally colourless 
blood of certain animals. The same causes that we have al- 
ready seen producing anaemia, are generally those also which 
tend to diminish the quantity of the peculiar animal matter to 
which the blood owes its colour. 

The blood, considered generally as a compound fluid, may 
be altered by its mixture with different substances not usually 



LESIONS OP THE BLOOD. 397 

found in it. In other parts of this work, I have mentioned 
cases in which there were discovered in the blood not only dif- 
ferent elements of the secreted fluids, but also sundry morbid 
productions, such as pus, encephaloid matter, entozoa, and cal- 
culous concretions. I do not now want to discuss the ques- 
tion whether these substances originated in the blood or were 
introduced into it ; whatever be their origin, it always happens 
that they are not merely mixed with the blood, but by combin- 
ing with it, alter it so far as completely to change its physical 
properties. In such cases, instead of blood, we often find only 
a curdy friable matter, of a dirty grey colour, and greater or 
less consistence, and resembling, as the case may be, either the 
semiconcrete pus of certain chronic abscesses, the sanies that 
flows from malignant ulcers, or the encephaloid masses of the 
liver, when broken up and reddened with a little blood. Some- 
times I have found such a matter in some vessels only ; some- 
times it existed in the greatest part of the circulatory system. 
Now, who could assert that in such cases the blood is not deep- 
ly altered in its nature. Besides, most commonly there are at 
the same time in the texture of many of the solids, morbid se- 
cretions, purulent or otherwise, formed of a matter that has the 
greatest analogy to that found in the vessels. Amongst the 
cases of this description I have had an opportunity of observ- 
ing, I shall adduce the following. In a woman who died at 
La Charite with all the symptoms of a chronic affection of the 
lungs and of the digestive passages, I found in front of the ver- 
tebral column an enormous tumour composed of an agglomer- 
ation of lymphatic ganglions, which, instead of their natural tis- 
sue, presented merely an inorganic pap, of a greyish or reddish 
colour. A similar substance appeared in the liver, in the form 
of roundish isolated masses ; it was also found in the spleen, in 
the cells of which it appeared to be deposited in place of the 
blood they usually contain ; lastly, in several points of the lungs, 
the lobules were infiltrated with the same substance. But that 
was not all ; for in both lungs, a great number of the branches 
of the pulmonary artery contained, instead of blood, a curdy 
matter of a reddish grey colour, resembling in appearance the 
morbid matter found in the mesenteric ganglions, liver, spleen, 



398 LESIONS OF THE BLOOD. 

and lungs. The right cavity of the heart, the pulmonary arte- 
ry, and its first divisions, contained a blood of little colour, and 
poor consistence. In another woman, who had a broken down 
cancer of the uterus, all the veins of that organ, and the trunk 
of the vena cava up to its passage under the liver, were full of 
a semifluid sanious matter of a greyish or reddish white. In a 
man far from being advanced in life, who had in a great many 
organs, encephaloid masses in a state of softening, the inferior 
vena cava, the renal and splenic, and some branches of the su- 
perior hepatic vein and of the pulmonary vessels, were filled 
with a kind of detritus of a reddish grey colour, without its 
adhering to the venous parietes, which, in this case, as well as 
in the preceding cases, presented no appreciable trace of alter- 
ation. Facts similar to those just mentioned have also been 
observed by others. Thus, Beclard mentions a case in which 
the heart and principal trunks of the vessels were filled with a 
solid clot, the interior of which presented numerous collec- 
tions of encephaloid matter. M. Velpeau found a mass of en- 
cephaloid in the midst of a clot of blood contained in the vena 
cava. He also cites a case of a man that died almost sudden- 
ly, after having shewn some symptoms of cerebral congestion, 
and in whom, upon examination, there was found through the 
whole extent of the circulatory system, a blood of a pultaceous 
consistence and blackish red colour, resembling the matter of 
certain abscesses of the liver. 

Bichat, in his Anatomie generate, has related a case in which 
the vena portae and the hepatic and splenic veins, instead of 
blood, were filled even to their very last ramifications with a 
greyish sanies. I have already brought forward cases in which 
a matter exactly similar to pus was found in the midst of a clot 
in one of the cavities of the heart, whithout any purulent col- 
lection existing elsewhere in the body. 

The alterations of the blood may be ascertained in still another 
manner than by simple inspection or chemical analysis. We 
know that, in general, the blood of one animal may be intro- 
duced into the body of another without any injury to the latter. 
But where that is not the case, and where the blood of a dis- 
eased individual, when introduced into the body of another in- 



LESIONS OF THE BLOOD. 399 

dividual, proves a real poison, it is impossible to resist the con- 
clusion that the nature of the blood is really changed. Now, 
let us see what has been observed on this head. 

M. Gendrin, in his work on fevers (vol. ii. p. 145) gives an 
account of a flayer whom he attended in a putrid fever with an 
eruption of gangrenous pustules. An ounce of blood drawn 
from one of the patient's veins was injected into the cellular 
tissue of the groin of a cat. The consequences to the poor an- 
mial were copious vomitings of bile, at first yellow, and then 
greenish, dyspnoea, a small, frequent, and irregular pulse, a 
dry and brown tongue, a constantly increasing prostration of 
strength, and, towards the close of the scene, some slight con- 
vulsive motions at intervals. Death ensued in six hours and 
fifty minutes after the injection. The appearances observed on 
examining the body are described as follows:— The skin of the 
groin did not adhere to the subjacent parts; the cellular tissue 
was soft and almost pulpy, and of an ashy yellow collour; it 
exhaled a fetid odour, and was dotted with small red spots ; 
the gastromucous membrane of the stomach and intestines was 
in the natural state, that of the respiratory passages was of a 
reddish brown ; the lungs, especially the left, contained black 
blood, and were full of brownish black spots ; the blood through- 
out the whole body was black and fluid; in the left pleura were 
about two ounces of very serous black blood; the heart was 
soft and flaccid ; there was no appearance of lesion in the brain 
or spinal marrow ; the body speedily began to exhale a fetid 
odour. 

Some blood that proceeded from an epistaxis that occurred 
in the same patient, was injected into the femoral vein of a 
dog. The animal exhibited the same series of symptoms as 
the one in the preceding experiment, which, in like manner, 
terminated in death. 

In another work (Histoire des Inflammations, vol. ii.) M. 
Gendrin relates some experiments in which he injected into 
the veins of animals the blood of persons labouring under con- 
fluent small-pox. Very severe symptoms, which rapidly prov- 
ed fatal, ensued ; and on opening the bodies, several organs 
were found in a state of high inflammation. 



400 LESIONS OF THE BLOOD. 

M M. Dupuy and Leuret introduced into the cellular tissue 
and veins of a sound horse, blood that came from horses affect- 
ed with malignant anthrax, (" chorion") and thus succeeded in 
producing the disease. It is, then, beyond all doubt, that in 
this case the blood itself was altered in its nature, since it 
proved capable of transmitting the affection. 

These facts bring to our recollection some others, for an ac- 
count of which we are indebted to the celebrated Duhamel. 
He has related a case where an ox, that was over-driven, hav- 
ing been slaughtered at an inn at Pithiviers, the butcher put 
into his mouth, for a few moments, the knife he had employed 
for the purpose. The consequence was, that in some hours 
afterwards his tongue swelled, his breathing became difficult, 
and then blackish pustules broke out all over his body: at the 
end of four days he died. The inn-keeper wounded himself 
with a bone of the same ox in the palm of his hand; his arm 
mortified, and he died in seven days. Two women having re- 
ceived some drops of the blood of the same animal, the one on 
her hand, the other on her cheek, these parts were seized with 
a gangrenous inflammation. Is it not likewise the simple con- 
tact of the blood of diseased animals that produces malignant 
pustule in man ? 

From these facts we must conclude that, under certain cir- 
cumstances, the blood may be altered in its intimate nature, so 
as to acquire noxious properties, which display themselves 
when it is mixed with the blood of healthy animals. 

The alterations of quality of the blood I have hitherto treat- 
ed of may be ascertained by experiment ; there are others, 
which, in my opinion, should likewise be admitted, simply 
from induction. If, for instance, an individual breathes an at- 
mosphere loaded with deleterious miasmata, or uses unwhole- 
some or insufficient food, and becomes sick in consequence, 
physiology would lead us to conclude that in such a case the 
blood has been at least the vehicle of the morbific matter re- 
siding in the air or food. If it be consistent with sound physi- 
ology to admit that bad diet must produce bad chyle, must not 
this in its turn, form bad blood ? But when we inject into the 
veins of animals different organized substances in a state of 



LESIONS OF THE BLOOD. 401 

putrefaction, the blood, in such a case, is not merely a vehicle 
to carry to the solids the deleterious substances that inflame 
them ; its unusual appearance leaves no room to doubt its be- 
ing really altered in its nature ; thus, it readily putrifies, it has 
lost the power of coagulating, the force of aggregation uniting 
its molecules is singularly diminished, and the most of the tis- 
sues become like filtres through which it oozes on every side. 
Various animal poisons, such as those of several of the snake 
tribe, and different mineral poisons, as mercury, for instance, 
act upon the blood in the same manner. 

There are, again, other modifications the blood may under- 
go, which will probably be studied with care at some future 
period, but of which we have as yet only some very vague no- 
tions. Thus, according to Bellingeri, the appreciable quantity 
of electricity is diminished in the venous blood both in old age 
and in certain diseases ; and if we are to believe Rossi, the 
blood, in severe fevers, presents characters, with respect to 
its electricity, that differ from those it has in the healthy 
state.* 

Barthez has said a great deal about a direct influence exer- 
cised by the nervous system over the blood. I grant that such 
an idea seems unfounded, if we consider the blood only as it is 
in its great vessels : but, in the capillaries, where it comes into 
contact with the solids, and is confounded with ihem, where it 
manifests signs of vitality, and where in conjunction with the 
nerves, it gives life to the organs it traverses ; in these, I say, 
who will venture to deny the influence of the nerves over it ? 
In the capillaries is exerted in full force that law of mutual de- 
pendence that connects all the parts of the system, and makes, 
of so many different elements, but a single whole — of so many 
partial lives, a single life. In them, the nerves must act on the 
blood, as the blood acts on the nerves. M. Dupuytren proved, 
lon^ ago, that cutting the pneumo gastic nerves prevents the 



* These facts, with respect to the modifications of the electricity of the blood 
are to be found in an excellent thesis On the alterations of the Fluids, sustain- 
ed before the Faculty, by M. Saucerotte, in August, 1828. 

Vol. I. 52 



402 LESIONS OF THE BLOOD. 

venous from being converted into arterial blood in the lungs. 
Dr. Mayer, from an experiment of his own, maintains that the 
nervous system has an influence over the blood, not only in the 
capillaries, but even in the large vessels. He observed, that, 
whenever he tied both pneumo-gastric nerves in animals, the 
blood in the whole of the pulmonary system coagulated, and 
the colouring matter separated from the fibrine ; and he took 
care to ascertain that these were not the consequences of death, 
by opening the animals the very moment they expired. 

The learned and indefatigahle Professor at Alfort, M. Du- 
puy, having lately tried upon horses the experiment of cutting 
the pneumo-gastric nerves in the cervical region, has ascer- 
tained that under such circumstances the quantity of fibrine in 
the arterial blood drawn from the carotid is notably diminish- 
ed. A certain quantity of blood, taken from the artery at the 
moment after the operation, contained twenty-one grains of 
fibrine. In four hours after, the same quantity contained only 
nineteen grains ; at the end of sixteen hours, eighteen grains ; 
at the end of forty hours, twelve grains. In fifty-two hours 
after the operation, the animal died in a state of suffocation ; 
and then the same quantity of blood, still taken from the caro- 
tid, contained but seven grains of fibrine. Now, it may be ask- 
ed, whether the section of the nerves produced this progressive 
dimunition of the quantity of fibrine directly ; or merely indi- 
rectly, by disturbing more and more the progress of sanguifi- 
cation in the lungs. 

M. Dupuy has likewise seen the fibrine diminished in quan- 
tity in the blood of a horse, affected with what is called roar- 
ing, after its respiration had been rendered laborious by run- 
ning it too long at full speed. In this case, the modification of 
the hsemotosis is in direct proportion to the difficulty of the 
respiration. 

Besides, it should be well ascertained whether, when an ani- 
mal is bled several times at very short intervals, there is not 
always less fibrine found in the last bleedings. 

M. Dupuy asserts that he found the blood entirely dissolved 
in the animal in which he had cut the pneumo-gastric nerves. 
He adds, that by injecting this blood into the jugular vein of 



LESIONS OF THE BLOOD. 403 

another horse, he produced in the latter a gangrenous affec- 
tion. These experiments would lead us to such extensive con- 
clusions, that I shall not venture to admit their results positive- 
ly, until they shall have been repeated. 

I have now stated the facts and arguments which, in the 
present state of the science, ought to lead us to acknowledge 
the existence of certain alterations in the blood. What I have 
already said on the subject, in my opinion, sufficiently demon- 
strates not only that these alterations are real, but also that 
they are often primary, that they precede those of the solids, 
and that, consequently, the origin of many diseases lies in the 
blood. If it is true that the mass of the blood may, in certain 
cases, be primarily altered, it follows that the existence of gen- 
eral disease is not merely imaginary. In fact, when all the ' 
tissues thus receive a vitiated blood, is it not consistent with 
sound physiology to admit that their regular modes of vitality, 
nutrition, and secretion, must be more or less deeply modified? 
We must either admit this conclusion, or deny the influence 
which, according to every physiologist, the blood exerts over 
each solid. It may then happen that one or more organs are 
affected in a more decided manner than the rest, and there 
may thus be produced in them various lesions that are only 
accidental and secondary ; but it is not in these lesions the 
origin of the affection lay : it is not on them all the symptoms 
depend ; nor, lastly, is it to them alone we are to have re- 
course to throw a light upon the true nature of the disease, as 
well as upon the treatment proper to be pursued. Experience 
also teaches us, that these lesions may be either severe or 
slight, present or absent, similar or dissimilar, and that, not- 
withstanding, the disease, though presenting so many different 
shades in its variable symptoms depending on these lesions, 
does not the less exist, as it really consists in the constant 
symptoms depending on the state of the blood. 

We must not, however, forget, that different alterations of 
the blood may exist, and have actually been observed, in per- 
sons presenting every appearance of good health. But such 
persons are on the brink of disease, and if any cause whatever 
chances to derange the equilibrium of their system, some of 



404 LESIONS OF THE BEOOD. 

the morbid phenomena that occur are sure to depend on the 
state of their blood. 

The diseases that seem to be connected with a morbid state 
of the blood may be either acute or chronic. I shall now 
offer some observations on each class successively. 

I have already established the fact that, under the influence 
of a state of general hyperaemia, every organ becomes excited, 
that death may result directly from such excitation, and that 
then a superabundance of blood is found all over the body, but 
in no part is there any serious lesion, any alteration of texture. 
In such cases there exists that state of pyrexia termed by no- 
sologists inflammatory fever. But if, instead of being simply 
in excess, the blood contains more fibrine than ordinary, its 
exciting power will be still greater, and what it did in the 
former case merely by its increased quantity, it will do now 
by its alteration in quality.* Under such circumstances, is it 
not evident that one of the indications to be fulfilled must be 
to dilute the fibrine with more water ? Hence the utility of 
administering plentifully aqueous drinks. M. Piorry has lately 
announced that one of the means of preventing the formation 
of false membranes in croup is to gorge the patient with 
water ; and we know that M. Magendie has seen the symp- 
toms of meningitis diminished by injecting water into the veins 
of the patient. 

The qualities of the blood may also be modified so as to give 
rise to the formation of the buffy coat. Now, the buff is not 
the result of a process of local irritation, inasmuch as it may be 
found before any such process exists, simply from the presence 
of a plethoric habit, or of a disposition to active sanguineous 
congestions ; it is found in pregnant women, who are so dis- 
posed to hyperemias subsequently to their delivery. The 



* An increase in the quantity of fibrine in the blood produces some remark- 
able effects on several vital actions. Thus MM. Prevost and Dumas have 
ascertained that the faculty of producing heat increases in animals in propor- 
tion to the number of the globules of the blood. 



LESIONS OF THE BLOOD. 405 

*ncients, then, were, perhaps, in the right in admitting an 
inflammatory state of the blood, of which the phlegmasia? of 
the solids were often merely the effect and external manifesta- 
tion as it were. On this inflammatory state of the blood would 
appear especially to depend, in certain cases, the phlegmasia? 
of the membranes of the serous and articulating cavities. In 
the first place, we are to observe that the morbid secretion that 
takes place in the surface of several serous membranes when 
inflamed, is exactly similar, in its physical and chemical pro- 
perties, to the albumino-fibrinous substance that forms the buff"; 
and that it may be organized even within the vessels (pro- 
vided there be a stagnation of the particles that form it) just 
as it is observed to become organized on the serous mem- 
branes on which it has been deposited. Now, if we mark the 
symptoms and progress of acute rheumatism, we find that very 
often a well marked febrile action, with a strong re-action, but 
without any symptom whatever of local affection, precedes the 
pains. In a word, there is first an inflammatory fever, and 
then rheumatism. Next observe the extreme mobility of these 
rheumatic pains ; they run along in a manner wherever the 
blood is distributed ; the application of leeches often removes 
the pain from one part, but it soon shifts to another ; and not 
unfrequently it quits the articulating tissues, and fixes upon 
different internal organs, producing by the derangement of 
their functions, symptoms more or less severe. It often hap- 
pens that a bleeding from a large orifice puts an end to the 
disease ; as if, by diminishing the mass of blood, it proportion- 
ably diminished the stimulus that produced all these shifting 
irritations. When that occurs, in the subsequent bleedings the 
buffy coat becomes less apparent, and at last disappears. But 
if, on the contrary, the rheumatism does not yield to venesec- 
tion, the buffy coat persists, and even becomes more apparent 
as venesection is more frequently resorted to ; the serum in- 
creases while the coagulum diminishes, and yet, be the coag- 
ulum ever so small, it is nevertheless covered with a buff as 
long as the rheumatism continues. 

What I have just been saying is, however, merely a proba- 
bility ; a point of view in which, when supported by facts, we 



40fi LESIONS OF THE BLOOD. 

may be permitted to consider an obscure question, to prepare 
the way to a full and complete solution hereafter. 

The introduction of certain deleterious substances into the 
blood, such as pus, putrid substances, and poisons from the 
three kingdoms of nature, beyond all doubt produces in it 
different changes, through which it loses its property of coagu- 
lating, and acquires a rapid tendency to decomposition. When 
these changes have been thus produced, the following phe- 
nomena are often observed ; 1. the nervous centres become af- 
fected, producing, according to the degree or nature of the 
affection, instantaneous death, a more or less considerable 
prostration of strength, convulsions, delirium, &c, or dyspnoea, 
palpitations, and vomitings ; 2. gangrene of one or more parts ; 
3. various serous or sanguineous exhalations ; 4. unusual gaseous 
secretions ; 5. a more or less general derangement of the func- 
tions of the different organs. 

On opening the bodies of the animals that presented these 
different morbid phenomena, we are sometimes unable to dis- 
cover any appreciable lesion; sometimes we meet with conges- 
tions or effusions of blood resembling those that had been 
observed during life; and, lastly, we sometimes discover greater 
or less alterations in the texture of the different solids. Along 
with these variable phenomena we always observe the two 
constant ones; 1. a remarkable fluidity of the blood; and, 2. 
a more rapid decomposition than ordinary of the blood itself, 
or of the different solids it penetrates. 

Where is the source of these various phenomena? Is it not 
evidently in the blood, into which the deleterious substances 
have been introduced? Now, those derangements of functions 
and organs produced by the experimenter, when he introduces 
different deleterious substances directly into the blood, are like- 
wise those that are produced by the sting or the bite of certain 
animals ; they are also those that take place from touching the 
flesh of animals that die of the plague, as well as those observed 
in small pox, measles, and scarlatina, of a malignant nature, as 
it is called. They are the same derangements that appear in 
persons exposed to putrid emanations, vegetable or animal, 
and to miasmata from the bodies of other persons that are them- 



LESIONS OP THE BLOOD. 407 

selves diseased and crowded in confined places where the air 
is constantly receiving the infection, without being changed by 
ventilation. Lastly, they shew themselves also in individuals 
whose blood is only imperfectly or badly repaired by insuffi- 
cient or unwholsome diet. 

In all these cases what do we discover to be the common 
element of the disease, if I may so express myself? Not any 
determinate lesion of one or more organs; for, on examination 
of the body after death, we often find none ; or else perhaps, 
we observe congestions resembling those found in a thousand 
other cases without producing any similar effects. What is it, 
then, I repeat? A vitiation of the blood by the commixture 
of deleterious substances; next, in consequence of such vitiation, 
an alteration of the functions of the nervous system ; and lastly, 
the blood that supports the organs, and the nervous system that 
animates them, having suffered a general injury, a constant, 
though not always appreciable modification of these organs in 
their functions or in their texture. 

To conclude, diseases resembling many of the preceding, 
whether in their symptoms, or in the appearances discovered 
after death, not unfrequently occur in cases in which no dele- 
terious substance has been introduced into the blood, and in 
which there is no direct proof that any alteration of that fluid 
has been the primary cause of the morbid phenomena. If, 
however, these phenomena are perfectly identical with those 
evidently produced by vitiated blood, if, on examining the body 
we cannot detect here any more than in the preceding cases 
any constant lesion in the solids, and if we always observe a 
certain number of fundamental symptoms whether these lesions 
exist or not, what is the conclusion consistent with true logic 
and sound philosophy? Certainly this, that here, as in the pre- 
ceding cases, it appears that the primary cause of the disease 
should be referred to the blood, which, in this case has altered 
its nature under the influence of unknown causes, as it has in 
the others in consequence of the commixture of various foreign 
substances. Perhaps there are cases of this kind in which the 
modification of the blood is itself only secondary to a modifica- 
tion of the nervous system. If, for instance, under the influ- 



408 LESIONS OF THE BLOOD. . 

ence of a strong mental emotion, this system, being suddenly 
perverted in its action, ceases to exert its proper influence over 
the different organs in which the blood is elaborated, deposited, 
and receives new materials, must not that fluid itself become 
altered in its turn? If so, thence must arise a number of or- 
ganic and functional derangements, varying greatly according 
to the mode and intensity of the primitive alteration of the 
innervation. In such cases, we may observe to occur sporad- 
ically those same diseases, typhoid or other, that we have just 
now seen prevailing epidemically under the influence of mani- 
fest causes of infection of the blood. All this is, undoubtedly, 
I again repeat, probable, but not certain ; but is there any 
greater degree of certainty in the opinion of those who regard 
all these derangements as the constant and necessary result of 
an acute inflammation of the stomach? I do not mean to say 
that this is never the case, and I am sure that no one would sup- 
pose me to entertain such an opinion. But, what I assert is, 
that often enough there is no proof whatever of the existence 
of this gastritis, that it can be admitted only by anology, and 
that there is as much physiology in one hypothesis as in the 
other. If then, there are on all sides only more or less proba- 
ble conjectures, it must be for the interests of the science that 
they should be all brought forward, provided that they are only 
given as conjectures, sufficiently founded, however, on facts 
and on physiological considerations, to entitle them to some 
share of attention. It appears to me quite certain that the 
theories of solidism in general, and that of irritation in particu- 
lar, are insufficient to account for all the facts that have been 
observed. Under such circumstances what should we do? 
Take another position, and try what we shall gain by it. 

So far, I have given a summary account of the cases of acute 
disease, the primary cause of which may, with some reason, be 
referred to an alteration of the blood. It seems, however, that 
certain chronic affections may also be referred to the same 
source. Let us now see what experience has to teach us on 
this head. 

When a person is in the habit of taking too much food, and 
that containing a great deal of azote, while at the same time his 



LESIONS OF THE BLOOD. 409 

body loses little by exercise or otherwise, his blood becomes 
very rich in fibrine, and he acquires a disposition to those in- 
flammatory diseases already mentioned. This is often all that 
is observed. In other cases, however, under similar circum- 
stances, a superabundant secretion of uric acid takes place in 
the kidneys, and gives rise to the complaint called the gravel. 
It often happens, too, that at the same time that this acid exists 
in the urine in much greater quantities than usual, it occurs as 
a morbid secretion in several other parts of the system. It fills 
the joints, is deposited between the surrounding fibrous tissues, 
and is found in masses between the fasciculi of several muscles, 
in the subcutaneous cellular tissue, and even in the spongy ex- 
tremities of the bones. I have found deposits of uric acid in 
all these parts simultaneously in the body of a patient that died 
at La Charite, whose case is to be found described in the in- 
augural dissertation of Dr. Fauconneau Dufresne. In such 
cases, it appears that this uric acid which thus appears in all 
parts of the body, and which we know from chemistry to be 
one of the most highly azotized proximate animal principles, is 
formed in excess in the blood under the influence of a strongly 
azotized diet; and that it is separated from it by its natural 
emunctory, as well as in the texture or on the surface of other 
organs. Accordingly, as Magendie remarks, the best way to 
put a stop to this superabundant secretion of uric acid is to 
change the diet of the person affected, and give him food con- 
taining as little azote as possible. Now, what is the prominent 
feature in all this ? The modification in the composition of the 
blood by the food, and the production of disease in conse- 
quence. According, then, to this view of the subject, there is 
something more in affections termed gouty, than a merely local 
irritation of an organ ; the latter is only a secondary phenom- 
enon, and we have other indications to fulfil than that of com- 
bating the pains in the joints by blood-letting. This theory is 
not incompatible with the fact that gravel and the different 
other deposits of uric acid are sometimes observed in persons 
who are far from living on such diet as I have just described; 
for we may conceive that independently of any influence of 
diet, the azote of the blood may become spontaneously predom- 
Vol. I. 53 



410 LESIONS OF THE BLOOD. 

inant, and consequently a greater quantity of uric acid be 
formed: it is however well known that this is not the most 
common case.* 

In the valuable work of Professor Dupuy on tuberculous af- 
fections, we find a fact that bears upon those just mentioned. 
He states, that in several cows in whose lungs were found 
abundant deposits of carbonate of lime, it was ascertained that 
the milk also contained a much greater quantity than usual of 
the same salt. At that advanced period of life in which we so 
frequently meet with deposits of phosphate of lime in several 
organs, it is, perhaps, in the blood, which then contains a super- 
abundance of that salt, we are to seek for the cause. 

Under the influence of other conditions in the external 
agents by which the blood is repaired or elaborated, namely, 
in the food and air, we observe different kinds of diseases pro- 
duced, whose source, in my opinion, should still be referred to 
the blood : moreover, these different diseases arise more or less 
frequently without there having been any previous modification 
of the air and food ; but, as the symptoms remain the same, it 
seems reasonable to conclude that the cause is the same, and 
that it always exists in the blood. In fact, where the effects 
are the same, is it not natural to conclude that the causes are 
also the same? Let us now consider some of those morbid 
states in the production of which the alteration of the blood 
appears to me to play a principal part. 

In times of scarcity, the whole population of a country has 
been known to be reduced to have recourse to the herbs of the 
field for support, and to live more or less exclusively on that 
poor sustenance. Now, in such cases, there has been always 
observed to appear, in consequence of such dieti the same mor- 
bid state, namely, dropsy; as if, in proportion as the blood be- 
came poorer and more deficient in fibrine, and approached, 
nearer to pure serum, it escaped the more easily from the ves- 



* It has been lately proved by the experiments of M. Edwards, that animals 
expire less azote during the cold season. Is not this one of the causes that may 
contribute to the superabundant formation of uric acid in cold, damp countries? 
This would be one secretion supplying the place of another. 



LESIONS OF THE BLOOD. 411 

sels, and accumulated either in the cellular tissue or in the dif- 
ferent serous cavities. This sort of serous diathesis may, how- 
ever, also appear spontaneously. I have elsewhere {Clinique 
Medicate, vol. iii.) recorded the history of some dropsical pa- 
tients, on the examination of whose bodies no appreciable al- 
teration in the solids could be detected, but in whom, instead 
of blood, there was nothing but serum; or at least the blood 
was in a very peculiar state throughout. It was devoid of col- 
ouring matter, and if it still contained any fibrine, it was such 
as had lost the power of coagulating, and it was dissolved in 
the superabundant serum which was the predominant chemical 
element. The dropsy accompanying such a state of the 
blood may appear either in persons who were previously in 
good health, or in those exhausted by long sickness. The first 
sort seem to have been in a manner disposed to it, from their 
pale, dead colour, their soft flesh, and the habitual state of semi- 
infiltration of their subcutaneous cellular tissue. If we apply 
leeches to their skin, in place of true blood, we often observe 
only a reddish serum issuing from the bites ; and, as, in such 
cases, it is not possible for coagulation to take place, it is some- 
times not without the greatest difficulty we can succeed in stop- 
ping it. Again, if we produce any irritation, there is but little 
appearance of redness; but a rapid accumulation of serum in 
the cellular tissue subjacent to the irritated part takes place. 
Thus, in this case, the result of the irritation is determined by 
the state of the blood; a very evident fact, and of some import- 
ance with respect to what may be drawn from it. Compare 
the bloodless skin of such individauls with the brown firm skin 
of stout healthy persons, with the bright rosy tint that marks 
the state of plethora ; and the three, with the habitually yellow 
tinge in persons of a bilious temperament, as it is called, who 
are yet in good health ; compare them, I say, and it will be 
evident that we cannot consider the fluid traversing the cellular 
tissue of the skin in these different individuals, as possessing 
the same properties, as containing the same principles, and as 
capable of acting similarly on the tissues ; now, this fluid is, af- 
ter all, but a part of the whole mass of the blood, and from the 
state of that part we can judge of the state of the whole. 



412 LESIONS OF THE BLOOD 

There is a disease which has shaken the belief of most of the 
solidists in their doctrine ; I mean the scurvy. The causes 
under the influence of which it is developed epidemically, the 
symptoms that characterize it, the remarkable state of blood 
itself, and the nature of the lesions discovered on examining the 
bodies all combine to prove that this disease depends on a 
primary alteration of the blood. But, there are some cases in 
which this vitiation of the blood in scorbutic persons is evidently 
the result of the bad qualities of the air and food. There are, 
again, other cases in which the disease comes on quite spon- 
taneously. In such cases, will any one deny that the blood is 
altered, because he cannot discover a cause for the alteration ? 
That would be forgetting that every day we observe lesions 
in the various solids, the determining cause of which is equally 
unknown to us. Besides, there are certain poisons, which, 
when introduced in small doses into the system for a long time 
together, at last produce, in the solids or in the blood, altera- 
tions exactly resembling those attributed to the scurvy : mer- 
cury is a poison of this kind. In such cases, we are induced 
to conclude from analogy, that the pernicious effects of that 
mineral often result from the primary alteration produced by 
it in the blood. Moreover, whatever be the external or inter- 
nal cause that has altered the blood, we observe in the solids 
different alterations well worthy of notice in this respect, that 
they prove that many a lesion apparently inflammatory, 
whether of an organ or of a function, is far from depending 
simply on a local morbid state, but, being connected with cer- 
tain conditions of sanguification, can be removed only by the 
return of that process to its natural state. Of this description 
are the numerous effusions of blood which so readily appear in 
all the organs of scorbutic persons, the tumefaction of the gums, 
the ulcers that occur on different parts of the cutaneous envel- 
ope, the congestion of the spleen, and the dyspnoea and palpi- 
tations of the heart of which they complain so much, &c. 
Now, if it is undeniable that there occur in scorbutic persons 
local affections very different from one another, that are pro- 
duced and kept up by a more general affection, which is their 
primary cause and common tie, is it not natural to suppose that 



LESIONS OF THE BLOOD. 413 

the scurvy is not the only disease so circumstanced ? Is it not 
natural to suspect, that in every case where we see in like man- 
ner a great many organs simultaneously affected in their nu- 
trition, where they are also simultaneously the seat of morbid 
secretions more or less similar in their nature, and where, 
moreover, as those simultaneous alterations of nutrition and 
secretion appear in the same order and manner in numbers of 
persons, it is impossible to assert that they are merely a chance 
assemblage ; it is not natural, I say, to suspect, that there as 
well as in the case of scurvy, there is in the system a pre- 
existing morbid condition that reveals its existence by these 
various local affections, so that to drive away the latter, we 
must attack the former ? Now, it is evident that this general 
morbid condition, of which every organ feels the influence, can 
hardly consist in any thing else than a modification of one or 
other of the two equally general systems, the sanguineous and 
nervous, which give life and support to each organ. Every 
one is acquainted, for instance, with the very striking features 
that characterize the scrofulous constitution, and every one 
must allow, on ever so little reflection, how impossible it is to 
confine such a state to any one particular part, whether the 
health still exist, or have been deranged by the alterations of 
nutrition taking place on all sides. In such cases, as there is 
no escaping the influence of the morbid condition which pre- 
vails over the whole system, and is present every where in the 
blood, every process of nutrition will be altered, and every 
secretion modified ; every hyperaemia accidentally produced 
will present a peculiar character in its symptoms, progress, 
duration, termination, and in the effects of therapeutic agents 
on it ; and every process of suppuration will furnish a fluid of 
equally peculiar characters. At the same time, there is not a 
single one of these alterations that may not be, in other cases, 
purely and simply a local affection ; such is the case, for in- 
stance, with pulmonary tubercles. That, however, is precisely 
what it is important to distinguish ; and I have already had oc- 
casion to establish this distinction when treating of tubercles. 

I have attempted to demonstrate, above, that there must be 
an alteration in the qualities of the blood, when there is an 



414 LESIONS OF THE BLOOD. 

alteration in the secretions. In consequence of the vitiation 
of these latter, there appear different morbid states in the pro- 
duction of which the qualities of the blood bear an important 
part. This is what occurs when the liver, for instance, no 
longer abstracts from the blood in proper quantities the mate- 
rials of the bile, they being either formed more abundantly 
than usual in the blood, or the liver, whether appreciably 
altered or not in its texture, having lost the power of secre- 
ting them. They then remain in the blood, and thence re- 
sults a yellow tinge, of greater or less intensity, in the skin and 
several other tissues. They may also escape from the blood 
with the elements of other secretions, and are to be found in 
the sweat, urine, lymph of the thoracic duct, fluid furnished by 
the mucous membranes, and that exhaled on the surface of the 
serous membranes. It even occurs, sometimes, that the bile 
forms deposits in the parenchyma of different organs ; where 
it is found accumulated, in the same manner as purulent col- 
lections are found in others. The resinous matter of the bile 
has sometimes been found in these various fluids and solids, 
but its yellow colouring matter is of much more frequent oc- 
currence. When the bile has once passed into the blood, to 
use the common expression, (which here again happens to be 
consonant with the science,) is it not reasonable to admit that 
that fluid, being altered by its unusual mixture with the ele- 
ments of the bile, can no longer exercise its regular influence 
over the different organs to which it is distributed ? Hence 
must arise different series of symptoms, according, 1. to the 
state in which these organs are ; and, 2. according as the mix- 
ture of the bile, or, at least, of its elements, with the blood, is 
more or less intimate, more or less prolonged, and more or less 
abundant. I may, perhaps, be mistaken ; but it seems to me 
that such a cause is very capable of producing some of those 
febrile states that have been denominated bilious fevers, a 
generic expression answering to more than one kind of morbid 
state. In fact, let us consider, in a number of individuals, how 
the symptoms of this disease are grouped together, and how 
they succeed each other ; let us observe the very remarkable 
yellow tinge of the face and conjunctiva, the slight icteric suf- 



LESIONS OP THE BLOOD. 415 

fusion which sometimes affects more or less the rest of the cu- 
taneous surface, the yellow tinge of the various excreted fluids, 
such as the urine, the mucus of the nasal fossee, and the expec- 
toration, the yellow coat of the tongue, and the very abundant 
bilious evacuations that often take place both above and below 
at the same time ; sooner or later after the appearance of this 
kind of bilious plethora, different functions become disordered, 
and at last the fever is kindled. Now, where are we to sup- 
pose the cause of all this to reside ? Is it in the irritation of 
an organ, of the digestive canal, for instance ? The fact of 
the matter is, that the existence of such irritation can often be 
admitted only by hypothesis. Before the fever begins, and 
while there is yet only a bilious state, to use the phrase of some 
writers, should we attempt to remove it by blood-letting ? Ex- 
perience has proved its inefficacy in such cases. If it was 
proved, on the contrary, that such medicines as evacuate the 
intestinal canal, when properly employed, restore the patient 
to health, we might explain their success by the greater activity 
they give the secretion of the liver, thereby producing a more 
complete depuration of the blood, and a cessation of the bilous 
symptoms, as they are called. I have had opportunities of ex- 
amining the bodies of different persons that had died of jaun- 
dice after suffering under the disease for several months ; they 
had fallen by degrees into a state of marasmus, and at last 
went off insensibly, without having ever presented symptoms 
of irritation in any one organ. In many of these cases, I could 
not discover any appreciable lesion in the liver, or other organs. 
What, then, was the cause of the disordered functions, emacia- 
tion, and death ? Was it the prolonged infection of the blood 
by the bile ? 

Every body knows what serious symptoms appear in an- 
imals when their ureters are tied ; and in man when any cause 
suspends the secretion of the urine or prevents its excretion. 
Whether the materials of the urine have not been separated 
from the mass of the blood, or have re-entered it, that fluid be- 
comes changed, and we observe that assemblage of symptoms 
comprized under the generic term of adynamic, putrid or 
ataxic fever, &c. In such cases a urinous smell is often ex- 



416 LESIONS OF THE BLOOD. 

haled from every part of the body, and the fluid itself is not 
unfrequently found in different parts of the system either in sub- 
stance or elements. 

An able observer, Doctor Dance, has described, in his in- 
augural thesis, the very peculiar state in which females are after 
their delivery ; he details the symptoms that may occur, and 
the particular form assumed by the diseases that may attack 
them, when the materials of the milk are not properly secreted 
by the mammary glands at the usual period, or else when the 
secretion is suddenly interrupted after having begun to take 
place. When the lacteous principles thus remain in the blood, 
or are thrown back again into it, I would ask, have they any 
share in the symptoms that supervene ? Is not this old idea 
supported by analogy with what occurs in consequence of the 
suspension of other secretions, the bile or urine, for instance ? 
If we consider the mixture of the materials of the bile or urine 
with the blood as the cause of various symptoms, why should 
we refuse to admit.that derangements of a more or less serious 
nature may also result from the presence of the principles of 
the milk in the blood, or from their not being eliminated ? In 
the present state of the science, are we to admit, without dis- 
cussion, the exactness of the following case, recently published 
by M. Graefe of Berlin?* 

A miller's wife was delivered of a child, which she suckled 
herself. On the eighth day after her confinement, while in per- 
fect health, the crash occasioned by the fall of a mill wheel 
frightened her so much, that her milk was totally suppressed. 
A state of constant febrile excitement then ensued, which de- 
generated into a tertian ague, during the course of which her 
legs became cedematous, and at the end of three weeks she be- 
came affected with anasarca and ascites. Three weeks after, 
as the dropsy did not diminish, recourse was had to paracen- 
tesis, and a bucket of fluid drawn off, which resembled whey, 
exhaled an acidulous odour, and, upon being boiled with dilute 
sulphuric acid, coagulated, and afforded a substance exactly 



* Revue Medicate, January, 1827. 



LESIONS OF THE BLOOD. 417 

resembling caseum.* Six weeks afterwards, the peritoneum 
being again filled, a second puncture was made, which gave 
issue to a fluid of a greenish yellow, without the least trace of 
caseum. The patiet recovered. 

This fact, and others already brought forward elsewhere in 
this volume, appear to demonstrate the possibility of the forma- 
tion of one of the most important principles of the milk in 
other parts of the system besides the breasts. In this last case, 
moreover, the succession of the symptoms is very remarkable ; 
subsequently to a sudden interruption of the lacteous secretion, 
we have first an intermittent fever, and next a dropsy, the fluid 
of which contains a matter resembling caseum. Was this im- 
mediate principle, which necessarily remained in the blood in 
consequence of the secretion of the milk, eliminated from it at 
the surface of the peritoneum ? Were the morbid phenomena 
produced both by the presence of the caseum in the blood, and 
by the process set up for its removal ? I know with how 
much reserve we must receive such facts, and, still more, ex- 
plain them. But yet, neither must we shrink from them; we 
must not, if I may use the expression, be afraid of their conse- 
quences, because they do not happen to harmonize with such 
or such pre-conceived ideas, seeing that it might well be that 
the error lay in the latter. 

It may be almost unnecessary for me to speak of the influence 
of the composition of the blood over that of the various se- 
creted fluids; and to remind the reader, that M. Magendie, 
by changing the food of different animals, and consequently 
modifying their blood, has made the urine and bile of some of 
the carnivorous species resemble those fluids in the her- 
bivorous; and that MM. Nicolas and Gueudeville have found 
in the blood of diabetic patients much more serum and far less 
fibrine than ordinary. f Thus, then, when the nature and the 



* I have already remarked, in another part of this volume, that cases of this 
kind are rendered less valuable, by the difficulty of distinguishing, in the present 
state of the science, between caseum and other proximate principles. 

t It is to be wished that these last experiments were repeated. 

Vol. I. 54 



418 LESIONS OF THE BLOOD. 

proportion of the constituent principles of the blood have un- 
dergone some of the changes already described, the result 
must be more or less appreciable modifications in the qualities 
of the secreted fluids, which may play a more or less import- 
ant part in the production of certain morbid states. Thus it 
is easy to conceive, that if many of the alterations in the saliva, 
bile, urine, serum, <fcc, are a direct result of a lesion of the 
organ in which these fluids are elaborated, there are others, in- 
dependent of the state of the secreting organ, and connected 
with an alteration of the common fluid from which they all 
emanate. If that is the case, we may go still farther ; and 
since it appears that most of the morbid productions are de- 
posited in the cellular tissue, in place of the small quantity of 
serum that usually lubricates it, we may ask if they also may 
not be accounted for by a vitiated state of the blood ; without, 
at the same time, meaning to assert, as I have already ex- 
plained, that many of them may not likewise result from a 
purely local alteration in the part where they are developed. 
In fact, what are these accidental productions but substances 
of various descriptions which are deposited in the framework 
of each organ, that is to say, in its cellular tissue, in place of 
its natural secretion ? Now, we can only conceive two rea- 
sons for their appearance ; either the blood on its arrival at an 
organ is wrongly elaborated by the nutritive parenchyma of 
that organ, or else it is altered before its arrival there. But, 
there are many cases in which there is no proof of there having 
been any thing wrong in the structure or action of the organ 
before the appearance of the morbid deposit ; and we may 
with especial reason doubt the previous existence of any fault 
in the part, when a great many organs simultaneously become 
the seat of similar accidental productions. 

I have now reviewed and discussed the most striking cases 
in which we may sometimes affirm, and sometimes only sus- 
pect, that the cause of the acute or chronic morbid state re- 
sides in the altered condition of the blood. I do not, however, 
mean to anticipate the future. I know not how far such re- 
searches may be pushed, so as to escape from the uncertainty 
in which the subject is still mostly involved. But what appears 



LESIONS OF THE BLOOD. 419 

to me particularly important at present, is to shew that at least 
they are not to be despised. I grant, that in the present state 
of the science, it is the part of a sensible man not to adopt the 
doctrine of humorism too lightly, by judging from facts many 
of which require a re-examination before they are finally ad- 
mitted ; and that we ought to be particularly on our guard 
against being in two great a hurry to make practical applica- 
tions of it ; but, neither ought we refuse examining into what 
is as yet only probable or doubtful, for fear of there being some 
chance of the simple probability being eventually raised by 
facts to the rank of a truth. Now, many of the questions 
proposed in this section appear to me to be of this description. 



420 LESIONS OF INNERVATION. 



SECTION V. 



LESIONS OP INNERVATION. 



In the preceding sections we have gone through the whole 
circle of the lesions that are appreciable by anatomy, without 
however, having been able to account by them for all the func- 
tional derangements of the organs ; besides, they have often 
appeared to us to be themselves but an effect, so that to assert 
that the whole disease lies in them is not unfrequently putting 
off the difficulty without solving it. We see then, that in the 
present state of the science, to attempt to explain every physio- 
logical and pathological phenomenon by a difference of arrange- 
ment of matter in a healthy or diseased living being, is to have 
recourse to hypothesis. Many authors, struck with the insuffi- 
ciency and the conjectural nature of this manner of explaining 
the phenomena, have had recourse to another, equally hypo- 
thetical, but at the same time, in their opinion, more compre- 
hensive and systematical. They assert that the primum mobile 
of every disease resides in the forces which direct the actions 
of each living particle, forces of which the organs appear to be 
only the instruments, and which, while they display in each or- 
gan an independent power from whence results its individual 
life, combine also into one single force, producing the life of 
the whole. All the different systems have been founded on one 
or other of these hypotheses in turn ; but, in my opinion, they 
would have been more complete and durable, had what was 
true and conformable with facts been selected from each. Let 
us now see how we can make use of the latter, as the science 
stands at present, since the other has not been able to account 
for every fact. 



LESIONS OP INNERVATION. 421 

There is, in man and the creatures near him in the zoological 
scale, an apparatus which appears to preside specially over the 
different vital actions, and to be the source of those various 
phenomena of sympathy and mutual co-operation without 
which there could not be a living whole. This is the appara- 
tus of innervation. In proportion, however, as we descend in 
the scale of beings, this apparatus becomes more and more 
simple, till it finally disappears; and yet life continues, and 
signs of sympathy and mutaal co-operation may still be ob- 
served. In those beings that are completely destitute of a 
nervous system life is nevertheless destroyed by agents which 
are generally considered to produce that effect in man solely 
by their deleterious influence over the nervous system ; thus, 
hydrocyanic acid can kill a vegetable as well as an animal. We 
see, then, that the forces which develope and support life may 
exist without the presence of a nervous system. Nay, vital 
actions can proceed even in an amorphous molecule, wholly 
destitute of organs. Notwithstanding, inasmuch as in man 
the accomplishment of these actions appears, according to our 
present knowledge of physiology, to be necessarily dependent 
on the nervous system, we may, by hypothesis, consider this 
system as the seat and instrument of the vital power. In the 
same manner, too, we may admit, for the sake of a more con- 
venient explanation of the facts observed, that there is formed 
in the nervous centres a fluid, which may be called nervous, 
vital, electro-vital, &c, and may serve to represent the un- 
known force by which these centres hold all the organs under 
their influence.* The term innervation merely expresses the 



* To admit the existence of a vital fluid, in order to explain the phenomena 
exhibited by living beings, is imitatiag the natural philosophers, who have long 
distinguished by the name of electric fluid, the unknown agent of a force that dis- 
plays itself in nature by the appearance of a determinate series of phenomena. 
That this vital fluid may be identical with the electric or some other fluid, is 
possible, but unimportant ; because we must nevertheless continue to give it a 
special name, as long as we cannot discover, from observation, an identity be- 
tween the phenomena occurring in organized, and in inorganic bodies. By this 
means, then, we remain faithful to the Newtonian system, which, in fact, is mere- 
ly that of observation, 1. in adopting, provisionally, the hypothesis of a fluid in 



422 LESIONS OF INNERVATION. 

influence exerted by this force every time a vital action takes 
place. When this force is disturbed or embarrassed in its ac- 
tion, we say there is a lesion of the innervation, and conse- 
quently a morbid state produced. Such lesion is sometimes 
followed by lesions of tissues appreciable by our various phys- 
ical means of investigation; and hence result all those altera- 
tions which are the study of pathological anatomy. Some- 
times, again, the lesion of innervation is followed only by a le- 
sion of the actions or functions of the organ affected. There 
are certain symptoms which never appear but in the first case ; 
while there are others which appear indifferently with or with- 
out appreciable lesions of organization. Hence we have often 
a perfect similarity between the symptoms, although the lesions 
discovered by anatomy are very dissimilar, or even although 
there are none to be detected in one of the cases ; hence, too, 
the little agreement often observed between the functional de- 
rangements of an organ, and the lesions observed in it after 
death ; because, before these lesions were produced, a disor- 
dered state of the innervation had arisen in the organ, which 
was of itself sufficient to derange its actions materially. 

Thus, in every disease not immediately produced by external 
violence, the symptoms that occur depend either on a lesion 
of the forces that animate every living part, (that is to say, on 
a lesion of innervation,) or, on a lesion of organization. The 
former is primary and constant; the latter is secondary, varia- 
ble in its nature, and inconstant in its existence. 



order to discover the laws of the vital phenomena ; and, 2, in considering this 
fluid as sui generis, because it manifests its existence by phenomena equally so ; 
it being a principle in natural philosophy to attribute to different forces phenome- 
na that differ from each other in appearance. We had certainly admitted, by 
hypothesis, the identity of cause and nature of the electric and magnetic phenom- 
ena, long before it was demonstated by the splendid researches of the modern 
philosophers ; but then, we allowed it was not demonstrated, and, until it was, 
the philosophers never thought of confounding the electric and magnetic fluids 
under the same name. In like manner, until it is proved that the forces which, 
in a living body, interrupt the play of the natural chemical affinities, maintain a 
proper temperature, and preside over the various actions of organic and animal 
life, arc analogous to those admitted by "natural philosophy, we shall act consist- 
ently with the principles of that science, by giving distinct names to these two 
kinds of forces, and employing ourselves in calculating the different laws they 
obey. 



LESIONS OF INNERVATION. 423 

In studying the diseases of the various apparatuses, in the 
second volume, we shall often have occasion to return to these 
two grand divisions ; in fact, we shall have to notice them in 
every case. How often do we observe various disorders of 
the digestion, circulation, respiration, and secretions, without 
being able to discover by dissection the least derangement in 
the organs that execute those functions. Still more frequently, 
again, in cases in which there has been some disorder of the 
different actions of animal life, the examination of the nervous 
centres will not reveal to us the cause. There are certain 
morbid states in which, before life has ended, the usual physical 
laws tend to resume their empire:' in such cases we may ob- 
serve in an individual, while still living, a remarkable diminu- 
tion of the resistance opposed by the body to the grand law of 
the equilibrium of caloric; the chemical affinities of inorganic 
matter begin to act, and there arise those phenomena long 
known by the name of putrid symptoms. This term, though 
it has been singularly abused, undoubtedly expresses something 
real, and its exactness in certain cases has been ascertained by 
observation. Perhaps we shall be able, at some future period, 
to explain, by lesions of organization, those remarkable phe- 
nomena which betray in the body while still endowed with life 
a less resistance to the ordinary laws of physics; but, until 
then, let us consider them as the external manifestation of a 
lesion of the vital powers themselves, and let us call them le- 
sions of innervation. 

Are we able to discover the causes that influence the pro- 
duction of these lesions of the vital force? We are, in certain 
cases. It appears to be affected primarily by a great many 
poisons, by the vegetable or animal emanations known by the 
name of miasmata, and by various modifications of the exter- 
nal agents which are incessantly acting on us, such as want of 
due exposure to the sun, too damp an atmosphere, and un- 
wholesome diet. If, for instance, a very slight difference in the 
moisture of the air is sufficient to produce a variation in the phen- 
pomena proceeding from what we call the electric fluid, why 
might not the same external influence also produce a variation 
in the phenomena proceeding from a cause, which being equally 



424 LESIONS OF INNERVATION. 

unknown with the electric fluid, may with equal reason be con- 
sidered by hypothesis as a fluid ? I would prefer, however, 
calling it vital, to calling it nervous fluid, since there are beings 
in which the same phenomena appear, although they have no 
trace of a nervous system. 

The same effects as are produced by external causes may 
also be produced by causes originating in the individual. Thus, 
whenever the blood is altered in quantity or quality through 
any of the causes already described, or whenever any solid is 
the seat of a severe lesion of organization, the vital force no 
longer displays itself by its ordinary phenomena, and there is 
a general disorder in the system which cannot be accounted 
for by any particular lesion, but is considered to be produced 
by sympathy: but what is sympathy? The existence of this 
general derangement is betrayed to us by symptoms which 
may be referred, 1. to an excitation of the vital force; 2. to its 
being lowered below the regular standard ; 3. to its perversion. 
Hence the existence, in every disease, of three fundamental 
dispositions, which, whether preceding it or produced by it, 
impress on it in every instance a peculiar character, direct its 
progress, produce its complications, determine its severity, and, 
lastly, regulate the indications of treatment. These may be 
termed the hyperdynamic, the adynamic, and the ataxic dispo- 
sition. Thus, then, in every disease, to study the various cir- 
cumstances external or internal, which, with or without an 
accompanying lesion of organization, determine the predomi- 
nance of one or other of these three dispositions ; to estimate the 
influence which these dispositions exert in their turn, over the 
organization ; to distinguish the modifications of treatment they 
require ; and to reduce to laws the results of these observa- 
tions; such should be the end of the physician. As for myself, 
it is sufficient for me to have pointed out this, without attempt- 
ing to traverse the path that leads to it; for that would be 
altogether quitting the domain of pathological anatomy. 



END OF THE FIltST VOLUME.